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 childs general health?
YesNo
 Are you being treated for any medical condition or have you been treated within the past 2 years?
YesNo
 Are you currently being treated by a physician for a specific condition?
YesNo
 Are your currently taking any medication?
YesNo
 Does your child have any allergies?
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 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 childs 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 teeth sensitive to
ColdHotSweetBiting
 Does your child have difficulty chewing food or does food get stuck between their teeth?
YesNo
 Has your child ever had an injury to your 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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(519) 473-WEST (9378)

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