Medical History Update Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.

(*) All fields required

Today's Date *

Patient Name *

Has there been any change to your child’s health since your last dental appointment? *
Yes No

If so, for what conditions? *

Is your child taking any kind of medication at this time? *
Yes No

If so, what? *

Does your child have any allergies (or adverse reactions) to any medications? *
Yes No

If so, what?? *

Patient's Home Address *

Street Address *

Apt #

City *

State *

Zip Code *

Father's Name *

Father's Home Number *

Father's Work Number *

Father's Cell Number *

Father's Email *

Mother's Name *

Mother's Home Number *

Mother's Work Number *

Mother's Cell Number *

Mother's Email *

Insurance Information

Are there any changes?
Yes No

If yes, please fill out the following:

Subscriber's Name

Social Security Number of Subscriber

Subscriber's Employer

Insurance Company's Name

Insurance Company's Address

Group #

Policy #

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)