Welcome to Smile Starters Pediatric Dentistry!

    SUITE 403 HARRISON, NY 10528
    TEL: (914) 777-1140 FAX: (914) 777-1139

    We are thrilled to welcome you and your family.
    Please fill out this form as completely as possible. If
    you have any questions, we are happy to help.

    Patient's Information and Health History


    Patient lives with

    Is this your child's first visit?

    Parents' Marital Status

    Guarantor (Person responsible for payment of dental services)


    Secondary Contact


    Insurance Information - Please give all your insurance cards to the receptionist.

    If no insurance, check here:

    Pharmacy Information

    Medical History

    Is your child currently under the care of a physician?

    Please describe your child's current physical health.

    Are all immunizations up-to-date?

    Does your child have any allergies to latex/medications (Penicillin) /food/other?

    Dental History

    Has your child experienced problems with previous dental work?

    Does your child take a fluoride multivitamin?

    Does your child brush his/her teeth daily with fluoride toothpaste?

    Does your child floss his/her teeth daily?

    Was your child bottle/breast-fed?

    Does your child have oral habits?

    Does your have speech, occupational, or physical therapy?

    Does your child play any sports?

    Authorization and Release

    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in my child's medical status. I also authorize Dr. Georgescu and Dr. Calamia to perform necessary dental procedures including, but not limited to, the use of nitrous oxide, local anesthesia and take any necessary radiographs to diagnose and/or treat my child's dental needs. I also authorize Dr. Georgescu and Dr. Calamia to release any information including the diagnosis and the records of treatment or examination rendered to my child during the period of such care to third party payer and/or other healthcare practitioners.