Child Patient Information/Medical History

If the child is under 18 years of age, we expect a parent of guardian to remain in the office for the child's entire visit.

Child's Name

Date of Birth

Child's Home Address

City

State

Zip

Child's Home Phone #

Cell Phone #

Email Address

EMERGENCY CONTACT INFO

Name & Relation

Home/Cell #

Health

Child's Physician

Phone #

Please describe the child's current physical health

Good

Fair

Poor

Has the child had/experienced any of the following:

Artificial Bones/Joint/Valves

Yes

HIV/AIDS

Yes

Diabetes

Yes

Blood Transfusion

Yes

If yes, what year?

Congenital Heart Defect

Yes

Heart Murmur

Yes

Heart Surgery

Yes

High/Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Hepatitis/Liver Disease/Jaundice

Yes

Rheumatic/Scarlet Fever

Yes

Abnormal Bleeding/Aspirin Use

Yes

Asthma/Tuberculosis

Yes

Cancer

Yes

Chicken Pox

Yes

Convulsions/Epilepsy

Yes

Handicaps/Disabilities

Yes

If yes, please specify

Hearing Impairments

Yes

Hive/Skin Rash

Yes

Kidney Problems

Yes

Lupus

Yes

Measles

Yes

Mononucleosis

Yes

Sickle Cell Anemia/Anemia

Yes

Tonsillitis

Yes

Has the child ever been hospitalized for any reason?

Is the child allergic to any of the following?

Motrin (Ibuprofen)

Yes

Dental Anesthetics

Yes

Codeine

Yes

Clindamycin

Yes

Latex

Yes

Penicillin

Yes

Additional Allergies

Please list any prescription or over the counter medication your child is currently taking: (If you have a list we can photocopy it)

Dental Health

Is the child's water fluoridated?

Yes

Is the child taking fluoridated supplements?

Yes

Does the child brush his/her teeth daily?

Yes

If yes, how many times?

Floss his/her teeth daily?

Yes

If yes, how many times?

Currently are your child’s teeth sensitive to heat, cold or anything else?

For Women

Are you taking birth control medication?

Yes

Are you pregnant?

Yes

If yes, how many months?

Are you nursing?

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I understand that it is my responsibility to inform this office of any change in my child's medical status. I understand that I am responsible for payment of services rendered and also for paying any co-pay and deductible that my Dental Benefit does not cover on the date of service. We schedule your time for your child and for your child only. Because of this, there will be a charge of $55.00 per ½ hour of appointment time billed to your account for missed appointments without 48 hours notice. We will try to confirm appointments 1-2 days prior to your scheduled time. However, if we can not reach you or you do not get the message, the appointment is still your responsibility.

Signature of Patient/Legal Guardian

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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