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.
Has your child complained about any dental problems?
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?
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?
Has child had any history of:
If other, please explain:
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.)