Medical History Update

PATIENT INFORMATION UPDATE

Child's Name:

Date of Birth:

Age:

Child's Name:

Date of Birth:

Age:

Child's Name:

Date of Birth:

Age:

Child's Name:

Date of Birth:

Age:

Child's Name:

Date of Birth:

Age:

CONTACT INFORMATION UPDATE

Patient's Primary Address:
(Address/City/State/Zip)

Home phone:

Cell phone:

Parent email:

Has your dental insurance company changed? Yes No

If you answered yes, please provide a copy of your new card to the dental business team member, at the check-in desk.

Medical History UPDATE

Please list NEW medical conditions (including allergies) that have been diagnosed since the last visit (For example: Heart condition, ADHD, autism, seasonal allergies, latex allergies, etc):

Patient:

Medical Condition:

Patient:

Medical Condition:

Patient:

Medical Condition:

Does the patient require an ANTIOBIOTIC before being seen? Yes No

Please list NEW OR CHANGES IN medication since the last dental visit:

Patient:

Medication:

Patient:

Medication:

Patient:

Medication:

Are there any dental concerns you would like addressed?

Consent for Dental Treatment

I am the parent and/or legal guardian of the patient and there are no court orders in effect preventing me from giving consent. I confirm that the information provided above is accurate to the best of my knowledge. I am aware that I must inform Growing Grins Pediatric Dentistry of any changed to my child’s medical history. I provide authorization for Growing Grins Pediatric Dentistry to perform any necessary dental services including, but not limited to, a comprehensive examination, cleanings, fluoride treatment, and any necessary dental treatment to maintain my child’s oral health. I have been advised that x-rays may be necessary to properly diagnose dental disease and to detect pathology. I have an expectation that risks and benefits for all dental treatment will be explained. I understand the most common dental complications include, not are not limited to, pain or discomfort during treatment, swelling, infection, bleeding, injury to adjacent teeth or surrounding tissues, development of a temporomandibular disorder, temporary or permanent numbness, and allergic reactions.

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