Health History 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. Please do not leave any lines blank. If it is not applicable, please write N/A.

(*) indicates a required field.

Today's Date *

Child's Name *

Nickname

Male/Female *

Date of Birth *

School

Grade

Address

City *

State *

Zip Code *


Father's Name

Father's Date Of Birth

Father's Address

Father's Home Number

Father's Employer

Father's Work Number

Father's Cell Number

Father's Social Security #

Father's D.L. #

Father's D.L. State

Father's Military Unit

Father's Military Rank

Father's Email Address


Mother's Name

Mother's Date Of Birth

Mother's Address

Mother's Home Number

Mother's Employer

Mother's Work Number

Mother's Cell Number

Mother's Social Security #

Mother's D.L. #

Mother's D.L. State

Mother's Military Unit

Mother's Military Rank

Mother's Email Address


Insurance Coverage

Dental Coverage? *

Name of Insured

Relation to Child

Social Security Number of Insured

Date of Birth

Employer Name

Address

Insurance Company Name

Phone Number

Insurance Address

Group ID

Family Physician or Pediatrician

Family Dentist

Whom may we thank for referring you to us?

Full name of brothers and sisters that are patients here

Permanent Home of Record

Permanent Home Phone Number

Dental History

Date of Last Dental Visit

For What Service?

Has your child complained about any dental problems?

Any injury to mouth?

Any unhappy dental experiences?

Any mouth habits - thumbsucking, nail biting, pacifier, etc?

Is your child still breast or bottle feeding?

Does child brush teeth daily?

Do you help your child brush?

How often?

Is dental floss used?

How often?

Is fluoride taken in any form?

Child's attitude to dentistry?

Do you desire complete dental service for your child?

Purpose of today's visit?


Health History

Is your child under the care of a physician now?

For what?

Allergic to any medications or anything else?

Taking any medication?

Please explain

Has child had any history of:

If other, please explain:

Describe your child's social development

Please list some words which describe your child's personality/temperament

Does child have any illness now?

Any special problems not listed above?

5. Signature

I understand that Stephen K. Brandt, DDS and his staff may submit forms for dental insurance claims as long as I provide all necessary forms and information necessary to complete the filing. An estimated deductible and co-payment will be calculated by the staff and payment for this amount is due on the day of treatment. I understand that my dental insurance is a contract between me and my insurance carrier and not between the insurance carrier and Dr. Brandt. I understand that I am still fully responsible for all dental fee.s I further understand that any expected payment from my insurance company is an estimate only and that I am responsible for any portion not covered or paid by insurance.

I understand that clinical findings may necessitate a change in the treatment plan which may increase my co-pay.

I understand that a no show, a broken or cancelled appointment within 24 hours advanced notice may incur a charge of up to $50.00 per patient per scheduled appointment.

I understand and agree to pay any interest fee that may occur if my account balance is not paid in full within 60 days. Interest fee on accounts over 60 days may be charged 1.5% monthly. Accounts over 90 days may be turned over to a collection agency. A collection fee of at least 45% of the total balance will be added to cover the collection expenses.

I have been given a copy of the Statement of Policy and Procedures.

I have read and fully understand this policy.

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

Date *