Child Health History Form

Child's Name:

Today's Date:

Sex

Male Female

lt is important to have complete answers. All information is, of course, confidential.

Is there a family history of Keloid Formation of tissue ?

Are you aware of your child having any particular dental problems?

Any discomfort or pain?

ls this your child's first visit to a dental office?

lf not, how long since last examination?

What was done to your child at that time?

Has your child ever had any serious illnesses, such as rheumatic fever, any kind of heart problem or heart murmur, diabetes, etc.?

Yes No

If yes, what?

Is your child sensitive to or allergic to any food or medication?

If so, what?

Who is your child's physician?

Address:

Phone #

Date of your child's last medical check-up:

ls your child under any treatment at present?

lf so, for what?

What medications does your child take?

Is child nursing?

If yes, for how long:

Any issues with nursing?

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

Social Security Number:

May we ask who recommended you to this office?

Child's name:

Date and year of birth:

Parent's Email

Sex

Male Female

Child's Height

Child's Weight

Home address:

City:

State:

Zip:

Parents Home/Cellphone #:

School:

Grade:

Parent #1's name:

Occupation:

Where do they work?

Phone:

Ext:

Parent #2's name:

Occupation:

Where do they work?

Phone:

Ext:

Responsible person:

What professional referred you to our office?

Name of Professional:

Type of Professional:

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.

Date:

Parent Name/Signature:

Insurance

Dental Primary Policy Holder: (N/A if not applicable)

Name of Dental Insurance Carrier:

Date of Birth:

Subscriber ID:

Group #:

SS # of Policy Holder:

If Secondary Dental Insurance:

Name of Secondary Dental Insurance Carrier:

Date of Birth:

Subscriber ID:

Group #:

SS # of Policy Holder:

Name of Medical Insurance Carrier:

Please upload a photo (FRONT & BACK ) of both Dental & Medical Insurance cards below.

As well as a photo of the FRONT of the policy holder's ID.

Files

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