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.

(*) indicates a required field.

Today's Date *

Patient Name *

Has there been any change to your child’s health since your last dental appointment?

If so, for what conditions?

Is your child taking any kind of medication at this time?

If so, what?

Does your child have any allergies (or adverse reactions) to any medications?

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?

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.)