Patient Information Update

Please type all information. Please include area code with all phone numbers.

Child's Name

Current Age

Family Record Update

Is there any change in your address or phone number?

Yes No

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

With whom does the child live?

Mother

Father

Guardian

Both Parents

Have you or child's other parent changed employment?

Yes No

Parent

Cell

Employer

Phone

Parent

Cell

Employer

Phone

Has your dental insurance carrier changed?

Yes No

New Insurance Carrier

Member ID

Group Number

Has your child changed schools?

Yes No

Name

Medical Update

Has your child's physician changed?

Yes No

Name

Phone Number

Address

City

State

Zip Code

Does your child have a medical condition(s) Dr. Moses should be aware of?

Yes No

Please list:

Is your child allergic to any medicines or foods?

Yes No

Please list:

Has there been any change in your child's health or medical history since the last dental visit?

Yes No

Please explain:

Is your child taking any medications, prescription or over the counter?

Yes No

Please list:

Has there been any injuries to the teeth, head or neck since the last dental visit?

Yes No

Please explain:

Is there any condition or problem you wish to bring to the attention of Dr. Moses?

Yes No

Please list:

Payment for services is due in full at the time of treatment unless prior arrangements have been made.

If this account should go to collections, you will be responsible for all collection fees and any attorney fees.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Relationship to Child

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