PLEASE PRINT

Date

Patient’s Name

Nickname

Home Address

Home Phone

City

State

Zip

Age

Birth date

Female/Male

If patient is a minor, give parent's or guardian’s name

How did you hear about our office?

Does the patient have or has he/she ever had any of the following conditions?

MEDICAL HISTORY

Heart Murmur

Yes No

Kidney Disease

Yes No

Rheumatic Fever

Yes No

Diabetes

Yes No

Asthma

Yes No

Epilepsy

Yes No

Heart Disease

Yes No

Nervous Disorder

Yes No

Thyroid Disease

Yes No

Tumor, Cancer

Yes No

High Blood Pressure

Yes No

Cardiac Pacemaker

Yes No

Lung Disease

Yes No

Measles

Yes No

Metallic Implant, Shunts, Pins or Rods

Yes No

Tonsillitis

Yes No

Sore Throats

Yes No

Ear aches

Yes No

Tuberculosis

Yes No

Glaucoma

Yes No

Chicken Pox

Yes No

Mumps

Yes No

Prolonged Bleeding When Cut

Yes No

Bad Breath

Yes No

Blood Transfusion

Yes No

Stained Teeth

Yes No

Injury to Front Teeth

Yes No

Cold Sore, Fever Blister

Yes No

Bleeding Gums

Yes No

Women: Are you Pregnant Now?

Yes No

ADD /ADHD  Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder

Yes No

AIDS

Yes No

Hepatitis/Liver Disease

Yes No

Chemical Dependency

Yes No

COMMENTS

Drug/ Food Allergy

Yes No

Developmentally Delayed

Yes No

If yes, to what medications/foods?

Age level patient is at

Is the patient taking any medications?

Yes No

Has the patient recently been under the care of a physician?

Yes No

If so, please list the medications

Reason

Name of Medical Doctor for above reason

Has the patient been hospitalized in the last 5 years?

Yes No

Has the patient had a serious illness or operation?

Yes No

If yes, please explain

Has the patient had difficulties in a dental office?

Yes No

If yes, please explain

Is there any other health information that should be known?

Last dental care

Date

Name

Address

Has any member of your family received dental treatment in this office before?

Yes No

If yes, please fill in the name

Names of other children in family

Name of family dentist

PEDIATRIC DENTISTRY SECTION

(To be filled out by parent or guardian)

Last well checkup

Name of pediatrician or primary care physician

Phone

Are test and Immunizations (DPT, diphtheria, tetanus, whooping cough, measles and polio, vaccines) up to date?

Yes No

Has he/she had a skin test for tuberculosis?

Yes No

Is he/she doing well in school?

Yes No

Does he/she get along well with other children?

Yes No

Does your child have any limitations to physical activities?

Has your child had any history of being under oxygen or general anesthesia?

Does the child have a specific problem that needs attention?

Yes No

Child’s pets and hobbies

Choose if applicable

Toothache Orthodontics Home Care Instructions

ORTHODONTIC SECTION

Is he/she a mouth breather?

Yes No

Have you ever been informed of any missing or extra permanent teeth?

Yes No

If so when

While asleep While awake

Has he/she had any injuries to the face, mouth, or teeth?

Yes No

Has he/she ever experienced any popping, clicking, pain or limitation of movement in the temporomandibular joint (TMJ)

Yes No

If yes, please explain

Does he/she experience headaches on a regular basis?

Yes No

Has an orthodontist been consulted previously?

Yes No

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete Address

Phone

RESPONSIBLE PARTY INFORMATION

Resident Parent

Last

First

Middle Initial

Middle Status

Address

Street

City

State

ZIp

How long at this address

Home Phone

E-mail Address

Cell Phone

Previous Address (if less than 3 yrs.)

Street

City

State

Zip

Social Security #

Birth date

Relationship to patient

Employer

Occupation

Yrs. Employed

Employer’s Address

Work Phone

Other Parent

Last

First

Middle Initial

Middle Status

Address (if not the same)

Street

City

State

Zip

Social Security #

Birth date

Relationship to patient

Home Phone

Work Phone

Employer

Occupation

Yrs. Employed

Employer’s Address

Cell Phone

DENTAL INSURANCE INFORMATION

Primary Insured’s Name

Insured’s Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insurance Phone #

Do you have dual coverage?

Yes No

Secondary Insured’s Name

Insured’s Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Insurance Phone #

I give my consent for the Doctors of this office to do a complete/emergency oral and dental examination on the patient named previously. X-rays that are necessary to properly complete the exam may be taken. If a cleaning, fluoride treatment and oral hygiene instructions are to be included in the first examination, I will be informed.

Any additional treatment received will be fully explained prior to starting treatment at each visit.

I agree to inform the doctors of any changes in medical or financial information.

I understand a credit report might be obtained.

Initials:

Requirement for Filing Insurance Claims: I authorize the release of any information relating to any dental claims and understand that I am personally responsible for all costs of dental treatment. I hereby authorize payment directly to to the dentist that performs services for treatment on my child.

By initializing this statement I accept financial responsibility for this child

Additional comments:

Date

Print (Parent or Guardian)

Signed (Parent or Guardian)

OUR BLOGS

Dr. LuLu: Scottsdale's Best for Kids' Dental Care

Why Choosing a Pediatric Dentist is the Best Option for Your Child:

Trust Dr. LuLu Pediatric Dentistry in Scottsdale, Arizona

As a parent, one of the most important decisions you can make for your child’s health is selecting the right dentist. While general dentists can care for patients of all ages, choosing a pediatric dentist specifically trained in the dental care of children offers numerous benefits. At Dr. LuLu Pediatric Dentistry in Scottsdale, Arizona, we understand the unique needs of young patients and strive to create a positive, comfortable dental experience.
In this blog, we will explain why opting for a pediatric dentist is the best choice for your child’s dental health, answer common questions parents often have, and highlight why Dr. LuLu is the best pediatric dentist in Scottsdale.

Why Choose a Pediatric Dentist for Your Child?

Choosing a pediatric dentist, especially a female dentist, has several key benefits that can make a big difference in your child’s dental health and comfort:

Specialized Training and Expertise

Pediatric dentists have specialized training that focuses on the unique dental needs of children. This includes understanding how children’s teeth develop, how to treat dental issues specific to their age group, and how to manage behaviors to ensure a smooth dental visit. Dr. Lu Lu is a highly trained pediatric dentist who uses her expertise to provide the best care possible for your child’s growing smile.

A Child-Friendly Environment

Pediatric dental offices are designed with children in mind. From playful, colorful décor to age-appropriate dental tools, a pediatric dental practice creates a fun and welcoming environment for young patients. Dr. Lu Lu’s office is tailored to ensure that your child feels at ease and comfortable, helping to reduce any anxiety they may have about visiting the dentist.

Preventive Care Focus

A local Scottsdale kids dentist like Dr. Lu Lu places a strong emphasis on prevention. Early dental visits are crucial for identifying potential issues such as cavities, misalignment, or gum disease. By starting dental care early, pediatric dentists can guide your child’s oral health development and prevent long-term dental problems.

Handling Dental Anxiety

Children can sometimes feel nervous about visiting the dentist, and it’s common for young patients to have dental anxiety. Pediatric dentists are trained to work with children, using techniques such as gentle encouragement, distraction, and age-appropriate explanations to make dental visits as stress-free as possible. Dr. Lu Lu has a calming presence and knows how to connect with kids to make them feel safe and comfortable.

Focus on Long-Term Oral Health

Best pediatric dentists in Scottsdale focus on the long-term oral health of children. From teething through to the teen years, a pediatric dentist is the right choice to monitor your child’s dental development, address early orthodontic needs, and create a foundation for lifelong oral health.

Frequently Asked Questions

When should I take my child to the dentist for the first time?

It’s recommended to schedule your child’s first dental visit by their first birthday or within six months of their first tooth eruption. Early visits help ensure that your child’s teeth and gums are developing correctly and allow you to establish a relationship with the dentist.

What makes a pediatric dentist different from a general dentist?

Pediatric dentists undergo additional training that focuses on the oral health needs of children, including their physical and emotional development. Pediatric dentists are experts at working with children of all ages, from babies to teens, and use techniques to ensure a positive and comfortable experience during each visit.

How can I help my child feel comfortable about visiting the dentist?

One of the best things you can do is set a positive example. Talk about the dentist in a calm and positive way, and avoid using negative words like “pain” or “shots.” At Dr. Lu Lu Pediatric Dentistry, we take extra care to ensure every child feels comfortable, using gentle techniques and offering reassurance throughout the process.

What are some common dental problems that children face?

Some of the most common dental issues in children include cavities, thumb-sucking, crooked teeth, and early signs of gum disease. Pediatric dentists like Dr. Lu Lu can identify and address these issues early, preventing bigger problems down the line.

Does my child need braces?

While most children don’t need braces until they’re older, some kids may need an orthodontic evaluation to assess alignment. A pediatric dentist can monitor your child’s teeth as they grow to determine when orthodontic care may be needed, ensuring they have a healthy smile as they enter adolescence.

We're here to give you the care you deserve

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PLEASE PRINT

MEDICAL HISTORY

Last dental care

PEDIATRIC DENTISTRY SECTION

ORTHODONTIC SECTION

EMERGENCY INFORMATION

RESPONSIBLE PARTY INFORMATION

Resident Parent

Address

Previous Address (if less than 3 yrs.)

Other Parent

Address (if not the same)

DENTAL INSURANCE INFORMATION

OUR BLOGS

Dr. LuLu: Scottsdale's Best for Kids' Dental Care

Why Choosing a Pediatric Dentist is the Best Option for Your Child:

Trust Dr. LuLu Pediatric Dentistry in Scottsdale, Arizona

Why Choose a Pediatric Dentist for Your Child?

Specialized Training and Expertise

A Child-Friendly Environment

Preventive Care Focus

Handling Dental Anxiety

Focus on Long-Term Oral Health

Frequently Asked Questions

When should I take my child to the dentist for the first time?

What makes a pediatric dentist different from a general dentist?

How can I help my child feel comfortable about visiting the dentist?

What are some common dental problems that children face?

Does my child need braces?

We're here to give you the care you deserve

We can't wait to meet you!

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