Child's Dental/Medical History Form

PLEASE FILL OUT COMPLETELY(THIS IS PROTECTED MEDICAL INFORMATION)

Today's Date

Age

Date of Birth

Child's Full Name

Preferred Name/ Nickname

Sex

Home Address/ZIP

Phone Number

Required Parent/Guardian Information (patient is a minor):

Parent/Guardian's Name

Relationship to child

Parent/Guardian Birthday

Parent/Guardian's Social Security Number

Insurance:

Does your child have Medicaid?

Yes No

If yes, what is the number?

Does your child have private insurance?

Yes No

If yes, what company?

Policy Holder's Name

Policy Holder's Social Security Number

Policy Holder's Birthday

Policy #

Company phone number

Company Address

Medical/Dental:

Is your child taking medicine for any reason? Please list names of all medicines , the reason for taking them, and how long he/she has been taking them.

Has your doctor or dentist ever required your child to take antibiotics due to a heart condition before having dental care?

Yes No

If so, why?

Is your child allergic to latex?

Penicillin?

Please list any other allergies

Does your child drink

bottled city well water

Does your child have, or has your child ever had, any of the following?

Rheumatic Disease/Heart Problems

Cancer

Hemophilia or bleeding problems

Asthma

Tuberculosis (TB)

Epilepsy

Please describe any checked problems, or list any other health problems

Has your child seen a dentist before?

Yes No

If so, when?

During the past six months, has your child had a toothache more than once when chewing?

Yes No Don't Know

Has your child ever had a traumatic experience at the dentist's office? Please describe

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

Parent/Guardian Signature

Date

PERMISSION TO RELEASE HEALTH INFORMATION

I, DO HEREBY GIVE PERMISSION TO RELEASE ANY INFORMATION NEEDED

TO THE FOLLOWING PERSONS (SPOUSE,PARENT,GUARDIAN,OTHER)

(THIS PERMISSION INCLUDES INFORMATION REGARDING MY DENTAL HEALTH CONDITION, FINANCES, APPOINTMENT SCHEDULING, ANY OTHER INFORMATION).

I understand that this authorization is valid and in effect until such time as I withdraw it in writing or in person.

Parent/Guardian Signature

Date

Your information will be encrypted.