MEDICAL DENTAL HISTORY

 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