PATIENT INFORMATION














RESPONSIBLE PARTY











DENTAL INSURANCE INFORMATION










If you have additional insurance, please complete the following questions:






Medical History


Is your child in good health?YesNo
Is your child being treated for any disease or illness? YesNo
Is your child taking any medications? YesNo
Is your child allergic to penicillin? YesNo
Is your child allergic to any medications? YesNo

Answer Yes or No if your child has ever had any of the following:

Rhumatic Fever YesNo
Heart Murmur YesNo
Any heart condition YesNo
Reaction to local anesthesia YesNo
Diabetis YesNo
Cancer YesNo
Hepatitis YesNo
Respiratory Disease YesNo
AIDS or HIV positive YesNo
Blood Disease YesNo
Liver or Kidney Disease YesNo
Epilepsy or Seizures YesNo
Latex Allergy YesNo
Cold Sore/Fever Blister YesNo
Autism YesNo
ADD/ADHD YesNo
Artificial Joint YesNo
Shunts YesNo
Thumb or Finger Habit YesNo

I hereby authorize Dr. Kemper to perform dental treatment and declare the above information is true and accurate.


When you come to our office for your child’s first visit, you will be asked to sign the HIPAA Patient Content form and the William E. Kemper DMD HIPPA Privacy Notice.