Information Update

INFORMATION UPDATE AND HEALTH STATUS REPORT
Child's Name (List all children coming for appointment)
Age (List ages for all children coming for appointment in the order above)
Parent #1: Name
Parent #1: DOB
Parent #1: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #1: Phone Number
Please enter a valid phone number.
Parent #1: Current Employer
Parent #1: Work Phone
Please enter a valid phone number.
Parent #1: Other Phone
Please enter a valid phone number.
Parent #1: Driver's License
Parent #1: Social Security
Parent #2: Name
Parent #2: DOB
Parent #2: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent #2: Phone Number
Please enter a valid phone number.
Parent #2: Current Employer
Parent #2: Work Phone
Please enter a valid phone number.
Parent #2: Other Phone
Please enter a valid phone number.
Parent #2: Driver's License
Parent #2: Social Security
Emergency Contact
Phone Number
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Relation
Indicate the best method to confirm your appointment:

Text:Phone:Email:
Indicate the number or email that will be used to confirm appointments:
Do you currently have dental insurance?

YesNo
If yes, Name of Insured
Insurance Company
Name of Employer
Insurance Phone Number
Please enter a valid phone number.
Has your child's medical history changed since your last visit?

YesNo
If so, how?
Has your child seen his/her physician since their last visit?

YesNo
If so, why?
Is your child taking any medication at the present time?

YesNo
If so, what?
Has your child had any head or neck injury in the last 6 months?

YesNo
If so, what?
Are there any dental problems you want us to evaluate?

YesNo
If so, what?
Is there anything else you would like to tell or ask us?

YesNo
If so, what?
Please remember that our office does have a 24 hour cancelation policy. If for any reason you are unable to keep your reserved appointment time we ask that you call our office at (972) 351-9700 as soon as possible to reschedule to avoid a $50 last minute cancelation/no show fee.
Date

MonthDayYear
Date
Signed

Clear
Relationship
Should be Empty:

INFORMATION UPDATE AND HEALTH STATUS REPORT