Michael M. Behle, D.D.S.
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Hobbies / Sports:
Child's Home #:
Child's Home Address:
Mother Stepmother Guardian
How long at current job:
Father Stepfather Guardian
Who is responsible for making appointments?
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Group # (Plan, Local or Policy #):
Policy Owner's Name:
Relationship to Patient:
Policy Owner's Birthdate:
Policy Owner's Employer:
Has your child ever been evaluated or had dental treatment before?
Has your child ever had a serious / difficult problem associated with previous dental work?
Have there been any injuries to the face, mouth, teeth or chin?
List any musical instruments played:
Have adenoids or tonsils been removed?
Has your child been informed of any missing or extra permanent teeth?
Has your child ever had any pain / tenderness in his / her jaw joint (TMJ / TMD)?
Does your child brush his / her teeth daily?
Does your child floss his / her teeth daily?
Date of last visit:
Is your child under the care of a physician?
Has puberty begun?
Girls - Has menstruation begun?
Please describe your child's current physical health:
Good Fair Poor
Please list all drugs that your child is currently taking:
Please list all drugs/things that your child is allergic to:
Metals / Nickel
ADD / ADHD
Allergies to Any Drugs
Allergic to Latex / Metals
Allergic to Plastic
Any Hospital Stays
Artificial Bones / Joints
Congenital Heart Defect
Convulsions / Epilepsy
Handicaps / Disabilities
HIV+ / AIDS
Kidney / Liver Problems
Rheumatic / Scarlet Fever
Please discuss any medical problems that your child has had:
Clenching / Grinding Teeth
Lip Sucking / Biting
Nursing / Bottle Habits
Thumb / Finger Sucking
Neighbor or Relative not living with you
I understand that the information that I given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status.
I authorize the dental staff to perform the necessary dental services that my child may need.
SIGNATURE OF PARENT OR GUARDIAN
This office reserves the right to verify the credit status of potential patients and/or parents prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.
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5202 Leavenworth St
Omaha, NE 68106