Welcome!

We would like to welcome you and your child to our office. Thank you for entrusting you child in our care. Our goal is to make ervery child's visit comfortable and educational.

Hung Pham, DDS, MS, Inc

Serramonte Pediatric Dentisty

1500 Southgate Ave, Suite 210, Daly City, CA 94015
(650) 756-0938

1
About Your Child
LAST
FIRST
MI
/ / Male Female
()
STREET ADDRESS
CITY
STATE
ZIP
2
General Information
Who is accompanying the child today?
Yes No
()
3
Parent's Information
Married Single Partnered Widowed Divorced Separated
Mother Father Step Mother Step Father Guardian
/ /
()
() ()

If you have insurance for your child, please fill out below:

/ /
()
Mother Father Step Mother Step Father Guardian
/ /
()
() ()

If you have insurance for your child, please fill out below:

/ /
()


** TO MINIMIZE YOUR COPAYMENTS, YOU MUST PROVIDE ALL INSURANCE PLANS YOU ARE CURRENTLY ENROLLED IN. WE WILL ONLY BE BILLING THE INSURANCE PLANS THAT WERE PROVIDED AT THE TIME SERVICES WERE RENDERED.

4
Dental History
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
()
Good Fair Poor
Y N
Y N
Y N
Y N
5
Medical History

Has the child experienced the following medical problem?

Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
6
INFORMED CONSENT
Signature of parent or guardian
Date

OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY OFFICE USE ONLY
I verbally reviews the medical / dental information above with the parent / guardian and patient named herein.