Online Application

Dear Parents,

Hi, I’m Dr. Scott Furrow, a Board Certified Pediatric Dentist, and I would like to welcome you to Leander Pediatric Dentistry. Children bring with them energy and excitement and are full of life and surprises. I know that how I treat each child will have a major influence on their perception of dentistry and I know that I can make it a positive memory. My team is dedicated to helping provide children with the necessary building blocks for creating a positive dental attitude. Below is information that you may find helpful in preparing for the first visit to our office.

PRIOR TO YOUR CHILD’S FIRST VISIT – We will contact you with instructions for completing paperwork necessary for treatment of your child. By completing most paperwork in advance, it allows both our patients and their parents to experience what it is that sets our office apart.

THE FIRST VISIT AND OUR POLICY – Before the age of 3 years, we ask that parents accompany their entire dental visit. Our dental experience has show that after this age, most patients excel by visiting the clinical area with their new found friends… patients and staff, with the parents in the reception area. By looking to us for interaction rather than their parents, this opportunity builds their self-esteem and confidence since they become proud of their independence. In addition to developing a relationship with myself and my team, the patients quickly realize that Leander Pediatric Dentistry is one rule of thumb, parents are allowed in the clinic and I enjoy visiting with parents as well. We know that your child’s first visit to the dentist is a very important milestone and we are confident that choosing Leander Pediatric Dentistry is a great decision!

Sincerely,
Dr. Scott

ID: Chart ID:
First Name : Last Name : Middle Initial :
Patient Is: Policy HolderResponsible Party Preffered Name:
Responsible Party (if someone other than the patient)
First Name : Last Name : Middle Initial :
Address: Address 2:
City, State, Zip: Pager:
Home Phone: Work Phone: Ext: Cellular:
Birth Date: Soc Sec: Driver Lic:
Responsible Party is also a Policy Holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder


Patient Information

Address: Address 2:
City: State / Zip: Pager:
Home Phone: Work Phone: Ext: Cellular:
Sex: MaleFemale Marital Status: MarriedSingleDivorcedSeparatedWidowed
Birth Date: Age: Soc Sec: Driver Lic:
E-mail: I would like to receive correspondence via e-mail

Section 2

Employment Status: Full TimePart TimeRetired

Student Status: Full TimePart Time

Medicaid ID:
 Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
 Pref. Hyg:

Section 3

Employment Status: Full TimePart TimeRetired

Student Status: Full TimePart Time

Medicaid ID:
 Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
 Pref. Hyg:


Primary Insurance Information

Name of Insured: Relationship to Insured: SelfSpouseChildOther
Insured Soc. Sec: Insured Birth Date:
Employer:
 Ins. Company:
Address:
 Address:
Address2:
Address 2:
City, State, Zip:
City, State, Zip:
Rem. Benefits: Rem. Deduct:


Secondary Insurance Information

Name of Insured: Relationship to Insured: SelfSpouseChildOther
Insured Soc. Sec: Insured Birth Date:
Employer:
 Ins. Company:
Address:
 Address:
Address2:
Address 2:
City, State, Zip:
City, State, Zip:
Rem. Benefits: Rem. Deduct:


Medical History

Patients Name: Date of Birth:

Although dental personnal primarily treat the area in and around your mouth, your mouth is a part of entire body. Health problems that you may have. or medication that you may be taking, could have and important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now? YesNo if yes, please explain:
Have you ever been hospitalized or had a major operation? YesNo if yes, please explain:
Have you ever had a serious head or neck injury? YesNo if yes, please explain:
Are you taking any medications, pills, or drugs? YesNo if yes, please explain:
Do you take, or have taken, Phen-Fen or Redux? YesNo
Have you ever taken Forsamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo
Are you on a special diet? YesNo
Do you use tobacco? YesNo
Do you use controlled substances? YesNo
Women: Are you pregnant/Trying to get pregnant? YesNo
Taking oral contraceptives? YesNo
Nursing YesNo
Are you allergic to any of the following?
AspirinPenicillinCodeineLocal AnestheticsAcrylicMetalLatexSulfa drugs
Other if yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive YesNo Cortisone Medicine YesNo Hemophilia YesNo Radiation Treatments YesNo
Aizheimer's Disease YesNo Diabetes YesNo Hepatitis A YesNo Recents Weight Loss YesNo
Anaphylaxis YesNo Drug Addiction YesNo Herpes YesNo Rheumatic Fever YesNo
Anemia YesNo Easily Winded YesNo High Blood Pressure YesNo Rheumatism YesNo
Angina YesNo Emphysema YesNo High Cholesterol YesNo Scarlet Fever YesNo
Arthritis/Gout YesNo Epilepsy or Seizures YesNo Hives or Rash YesNo Shingles YesNo
Artificial Heart Valve YesNo Excessive Bleeding YesNo Hypoglycemia YesNo Sickle Cell Disease YesNo
Artificial Joint YesNo Excessive Thirst YesNo Irregular Heartbeat YesNo Sinus Trouble YesNo
Asthma YesNo Fainting Spells/Dizziness YesNo Kidney Problems YesNo Spina Bifida YesNo
Blood Disease YesNo Frequent Cough YesNo Leukemia YesNo Stomach/Intestinal Disease YesNo
Blood Transfusion YesNo Frequent Diarrhea YesNo Liver Disease YesNo Stroke YesNo
Breathing Problem YesNo Frequent Headaches YesNo Low Blood Pressure YesNo Swelling of Limbs YesNo
Bruise Easily YesNo Genital Herpes YesNo Lung Disease YesNo Thyroid Disease YesNo
Cancer YesNo Glaucoma YesNo Mitral Valve Prolapse YesNo Tonsilitis YesNo
Chemotherapy YesNo Hay Fever YesNo Osteoporisis YesNo Tuberculosis YesNo
Chest Pains YesNo Heart Attack/Failure YesNo Pain in Jaw Joints YesNo Tumors or Growths YesNo
Cold Sores/Fever Blisters YesNo Heart Mumur YesNo Parathyroid Disease YesNo Ulcers YesNo
Congenital Heart Disorder YesNo Heart Pacemaker YesNo Psychiatric Care YesNo Venereal Disease YesNo
Convulsions YesNo Heart Trouble/Disease YesNo Yellow Jaundice YesNo
Have you ever had any serious illness not listed above?
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