PEDIATRIC DENTAL AND MEDICAL HISTORY UPDATE
Today’s date:
/
Month
/
Day
Year
Date
Name
Last, First
DOB
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Would you like to add any more children to the form?
Yes
No
Additional Children
Last Name, First Name
DOB
Child 2
Child 3
Child 4
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Have there been any changes to your contacontact information?
Yes
No
Start of Contact Information Section
Street Address
City, State, Zip Code
Home phone:
Cell phone:
Email
example@example.com
End of Contact Information Section
Have there been any changes to your insurance information?
Yes
No
Start of Dental Insurance section
Dental Insurance Company
Policy Holder's Name
Policy Holder’s Date of Birth:
/
Month
/
Day
Year
Date
Policy ID number
End of Dental Insurance stopper
Have there been any changes to the patient’s medical history?
Yes
No
Please list:
Does the patient have any heart problems ththat require pre‐medication before receiving dental cation before receiving dental treatment?
Yes
No
Please list:
Is the patient allergic to latex?
Yes
No
Is the patient currently taking any medication?
Yes
No
Please list:
Do you give consent to have diagnostic & preventive dental services which include (but are not limited to thefollowing): exam/consultation, as well as prophylaxis (cleaning), and fluoride treatment to be performedon the listed patient(s)?
Yes
No
Do you give consent for personal health information to be discussed through email, phone for personal health information to be discussed through email, phone calls, text message, and voicemails?
Yes
No
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Parent/Guardian’s Signature Parent/Guardian’s Signature
Clear
Parent/Guardian’s NameParent/Guardian’s Name
Doctor’s Signature
Clear
Submit
Should be Empty: