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

    OUR CLINIC

    1295 Riverbend Road Suite 260 London, Ontario

    reception@westfivedental.ca

    CONTACT US

      BOOK AN APPOINTMENT NOW

      (519) 473-WEST (9378)

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