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About
- About Northshore Dental
- Meet the team
Services
New Patients
- New Patients Form (Adult)
- New Patients Form (Children)
Contact Us

Home
About
- About Northshore Dental
- Meet the team
Services
New Patients
- New Patients Form (Adult)
- New Patients Form (Children)
Contact Us

schedule an appointment (425) 486-6511

Home
About
- About Northshore Dental
- Meet the team
Services
New Patients
- New Patients Form (Adult)
- New Patients Form (Children)
Contact Us

schedule an appointment

Patient Health & Dental Information

help us get to know you better– complete your new patient forms online or print them out

For your convenience, you may fill out the Child Patient Form online below, or download it to complete at home and bring with you to your child’s visit.

To the parents/guardians of the patient: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat the patient.

PATIENT INFORMATION

Name(Required)

First Middle Last

Date of Birth:(Required)

Month

Day

Year

Pronouns:

Parent’s/Guardian’s Name:

Relationship to Patient:

Email Address:(Required)

Home Phone:

Cell Phone:

Work Phone:

Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you (the adult) or the patient (the child) had:

A cough that’s lasted longer than three weeks

A cough that produces blood

Active Tuberculosis

PATIENT’S DENTAL HEALTH HISTORY

What is the reason for your visit today?

How would you describe the patient’s oral health?

Excellent

Good

Fair

Poor

Does the patient currently have any dental pain or discomfort?

If yes, where?

Is this the patient’s first visit to a dentist?

If no, when was the patient’s last dental exam?

What was done at that appointment?

When was the last time the patient had dental x-rays taken?

Please select your answers to the following questions.

Has the patient had any problem with dental treatment in the past?

If yes, please describe what happened:

Has the patient had any problems with teeth coming in or losing teeth?

Does the patient use fluoride or nano-hydroxyapatite toothpaste when brushing teeth?

How often are the patient’s teeth brushed?

At what time(s) of day are the teeth brushed?

Has the patient ever worn braces or other orthodontic appliances?

Has the patient ever had a serious injury to the head, mouth or teeth?

If yes, please describe what happened and when it happened:

Does the patient play any contact sports or participate in active recreational activities?

If yes, please describe those activities here:

Is your home water supply fluoridated?

What is the patient’s primary source of drinking water?

Tap

Bottled

Filtered

Well

Does the patient take fluoride supplements?

Does/did the patient use a pacifier or suck his/her thumb or fingers?

At what age did the patient stop breastfeeding?

At what age did the patient stop bottle feeding?

Has the patient ever experienced any sleep-related breathing disorders?

Mouth breathing

Snoring

Trouble breathing during sleep

PRIMARY DENTAL INSURANCE

Insurance company:

Group number:

Subscriber ID number:

Subscriber's name:

Birth date:

Month

Day

Year

Employer providing insurance:

SECONDARY DENTAL INSURANCE (if applicable)

Insurance company:

Group number:

Subscriber ID number:

Subscriber's name:

Birth date:

Month

Day

Year

Employer providing insurance:

Hours

Monday

8:00AM - 5:00PM

Tuesday

8:00AM - 5:00PM

Wednsday

7:00AM - 4:00PM

Thursday

8:00AM - 5:00PM

Friday - Sunday

Closed

Location

Northshore Dental

6502 NE 181st St., Kenmore, WA, 98028

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