Child Health History Form

Patient's Name*

Name you like to be called

Age*

Birthdate*

Date

Do you play a musical instrument?

YesNo

If yes, type:

Girl Scout/Brownies* Troop #

Boy/Cub Scouts* Troop #

School

Parent/Guardian Name

Cell Phone*

Please enter a valid phone number.

Cell Carrier*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

How long at this address?

Previous Address

Street Address

Street Address Line 2

CityState

Zip Code

Social Security #*

Marital Status*

Email*

example@example.com

Occupation

Employer

No. of years employed

Who may we thank for referring you to our office?*

Name of Child's Other Parent(s)

Do you give the child's other parent(s) full access to the child's dental and financial records?

YesNo

Primary Insured’s Name

DOB

Date

Primary Insured’s SS#

Insurance Co:

Insurance Phone

Please enter a valid phone number.

Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insured’s Employer

Insurance Group Number

ID Number

Do you have dual coverage?

YesNo

Insured’s Name

DOB

Date

Insured’s SS#

Insurance Co:

Insurance Phone

Please enter a valid phone number.

Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insured’s Employer

Insurance Group Number

ID Number

Physician’s Name

Physician’s Phone

Please enter a valid phone number.

Dentist's Name

Dentist's Phone

Please enter a valid phone number.

Are you currently under any medical treatment?*

YesNo

If yes, please explain

Do you have pain, clicking, and/or popping noises in the jaw?*

YesNo

If yes, please explain

Are you aware of either clenching or grinding of teeth?*

YesNo

If yes, please explain

Do you have frequent headaches?*

YesNo

If yes, how often?

Do you have ear problems? (Aches, ringing, dizziness, fullness)*

YesNo

If yes, please explain

Do you have difficulty breathing through the nose?*

YesNo

If yes, please explain

Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?*

YesNo

If yes, please explain

Do you have speech problems, or are you in speech therapy?*

YesNo

If yes, please explain

Have you had your tonsils and/or adenoids removed?*

YesNo

If yes, please explain

Has there been any history of:*

Do you bleed easily?*

YesNo

If yes, please explain

Is there a tendency to faint or become dizzy?*

YesNo

If yes, please explain

Do you have allergies? (Sulphur, penicillin, novocain, etc.)*

YesNo

If yes, please explain

Are you currently taking any medication?*

YesNo

If yes, please list

Do you have a heart condition?*

YesNo

Do you pre-medicate?*

YesNoNo Cardiologist

Do you have sleep apnea?*

YesNo

If yes, please explain

Do you smoke or chew tobacco?*

YesNo

If yes, please explain

Have there been any injuries to the teeth?*

YesNo

If yes, please explain

Have you had any permanent teeth extracted?*

YesNo

If yes, please explain

Have we treated any other family members?*

YesNo

If yes, who

Section A: Parent/Legal Guardian Giving Consent

Patient's Legal Name

SECTION B: TO THE PATIENT - PLEASE READ THESE STATEMENTS CAREFULLY

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

COMMUNICATION: Surf City Smiles reserves the right to communicate with the responsible party via text/e-mail regarding patient's treatment and finances. It is your responsibility to let us know if you would like to opt out of this feature.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our notice is available upon request with this consent. We encourage you to read it carefully and completely before signing this consent.

OFFICE PROCEDURES: As a part of your complimentary consultation our office will take x-rays and photographs of your teeth. This is for diagnostic purposes and will not be billed to you or your insurance company. It is near impossible for our doctors to give accurate treatment plans without these records.

USE OF RECORDS: Surf City Smiles has the right to use patient photographs, x-rays, videos, and other photographic reproduction for the purpose of communication with your current and future dental and medical professionals. Our doctors also reserve the right for records obtained in our office to be used for professional, academic, patient education, and practice promotion. This includes, but is not limited to use on the Surf City Smiles website, brochures, and social media sites.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will make available upon request a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revision of our notice, at any time by contacting:

Telephone: 714-462-5410
Email: hello@surfcitysmiles.com
Address: 10172 Adams Ave, Huntington Beach, CA 92646

RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice or your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

SECTION C: SIGNATURE

I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THE CONTENTS OF THIS CONSENT FORM AND YOUR NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT BY SIGNING THIS CONSENT FORM I AM GIVING MY CONSENT TO YOUR USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES AND HEALTH CARE OPERATIONS

Signature*

Clear

Date*

Date

Child Health History Form

Insurance Information

Medical/Dental History

Consent for Use and Disclosure of Health Information