New Patient Forms

Welcome to Smile Pacific Highlands Ranch!

In order to make it easy for your first visit with us, you can fill out our new patient form electronically. If you have any questions you can always call our office at: (858)-387-6453 and we’ll be more than happy to help you out.

Thank you! All information is transmitted over a secure connection and will never be distributed or sold to any third parties.

​​​​​​​We are compliant and observe all HIPAA Regulations.
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Personal Information

First Name *
Last Name *
Nickname
Sex *
Date of Birth *
Age *
Is this your child's first dental visit?
How did you hear about our office? *
Is your child adopted? *
Who has legal guardianship of your child? *
Names & Ages of Siblings *
Reason for this visit

Medical and Dental Information

Medical Information

Doctor's Name
Doctor's Phone
Doctor's Address
Is your child taking medication?
Has your child every been hospitalized?
Has your child had a history or difficulty with any of the following: *
Does your child brush regularly?
Does your child have any emotional or school problems? *
Allergies to Food or Medications *

Dental Information

Does your child brush regularly?
Does an adult assist with brushing?
Does your child floss?
Does an adult assist in flossing?
Has your child ever had any injuries to his teeth, mouth or head?
Has either parent or child been treated orthodontically?
Name of Orthodontist
How would you expect your child to behave in our office?
How may we help to make this visit a positive experience for your child?
Describe your child:

Responsible Party Information

Responsible Party Information

(holder of insurance)

First Name *
Last Name *
Relationship to patient *
Address *
City, State, Zip *
Cell Phone *
Other Phone
Date Of Birth *
Occupation *
Employer
Email Address *
Who can we thank for referring you to our practice?


​​​​​​​Other Parent's Information

Relationship to patient? *
Name *
Employer
Occupation
Cell Phone *
Address
City, State, Zip
Date Of Birth


​​​​​​​Primary Dental Insurance

Policy Holder's Name
Social Security Number
Policy Number
Insurance Company
Insurance Address
Insurance Phone
Does your child have secondary dental insurance?

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