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)
Father's Name
Father's DOB
Father's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Phone Number
Please enter a valid phone number.
Father's Current Employer
Father's Work Phone
Please enter a valid phone number.
Father's Other Phone
Please enter a valid phone number.
Father's Driver's License
Father's Social Security
Mother's Name
Mother's DOB
Mother's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone Number
Please enter a valid phone number.
Mother's Current Employer
Mother's Work Phone
Please enter a valid phone number.
Mother's Other Phone
Please enter a valid phone number.
Mother's Driver's License
Mother's 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?
Yes
No
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?
Yes
No
If so, how?
Has your child seen his/her physician since their last visit?
Yes
No
If so, why?
Is your child taking any medication at the present time?
Yes
No
If so, what?
Has your child had any head or neck injury in the last 6 months?
Yes
No
If so, what?
Are there any dental problems you want us to evaluate?
Yes
No
If so, what?
Is there anything else you would like to tell or ask us?
Yes
No
If so, what?
Date
/
Month
/
Day
Year
Date
Signed
Clear
Relationship
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