Form: Medical Dental History 2018-02-27T05:22:31+00:00

MEDICAL DENTAL HISTORY

MEDICAL/DENTAL HISTORY FORM – PEDODONTIC-CHILD

     Do you have dental insurance?
    YesNo
    If YES, complete the following
     Primary Insurance
     Secondary Insurance
     Has there been any change in your general health?
    YesNo
     Is your child being treated for any medical condition or have you been treated within the past 2 years?
    YesNo
     Is your child currently being treated by a physician for a specific condition?
    YesNo
     Is your child currently taking any medication?
    YesNo
     Do you bleed or bruise easily?
    YesNo
     Have you ever been hospitalized?
    YesNo
     Has your child ever received general anesthesia?
    YesNo
     Has your child ever had an adverse reaction to local anesthetic?
    YesNo
     Does your child have any allergies to medications?
    YesNo
     Does your child have any other allergies?
    YesNo
     Does your child currently have any of the following conditions?
    Heart Murmur
    Joint replacement
    Osteoporosis
    Rheumatic Fever
    Jaundice
    AIDS/HIV
    Hepatitis A/B
    Thyroid Disease
    Mental Illness
    Diabetes
    Heart Attack
    High Blood Pressure
    Cancer
    Arthritis
    Epilepsy
    Asthma
    Liver Disease
    Drug/Alcohol Abuse
    Kidney Disease
    Stroke
    Radiation Therapy
    Steroid Therapy
    Artificial Joint Replacement
     Is there anything else the doctor needs to know regarding your child's medical health?
    YesNo
     Dental History
     Has your child ever been to the dentist before?
    YesNo
     Is your child currently experiencing any pain or discomfort?
    YesNo
     Are any of your child's teeth sensitive to
    ColdHotSweetBiting
     Does your child have difficulty chewing food or does food get stuck between his/her teeth?
    YesNo
     Has your child ever had an injury to his/her jaw or face?
    YesNo
     Has your child been examined by an ORTHODONTIST regarding growth patterns and development?
    YesNo
    PATIENT CERTIFICATION AND CONSENT
    I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.
    ___________________________________________________
    SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)

    To be signed at your appointment

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