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.