Health History Update

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 *

Child's Full Name *

D.O.B. *

Street Address *

City *

State *

Zip Code *

List any dental insurance or financial policy changes:

Home Number

Work Number

Cell Number

Email Address

Child lives with
Both Parents Mother Father Other

If other, please list

If not living with both parents, who is legal guardian?

Does your child have a heart problem or heart murmur that requires antibiotics before dental treatment? *
Yes No

If yes, please explain:

Is your child allergic to penicillin or other medicines? *
Yes No

If yes, please explain:

Is your child allergic to Latex? *
Yes No

Is your child taking any medication? *
Yes No

If yes, please explain:

Is your child presently under the care of a physician for any medical problems? *
Yes No

If yes, please explain:

Pharmacy Phone Number

Name, Address and Phone of Child's Physician

Physician's name

Street Address

City

State

Zip Code

Phone Number

Date of Child's Last Physical Exam

Has your child had any injuries to mouth, teeth, or jaw since the last visit?
Yes No

If yes, please explain:

Signature

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.)

Parent or Guardian Print Name *

Relationship to Patient *

Date *