Cobourg CHILD Medical/Dental History Form

  • Medical & Dental History- Child

    Please take a moment to tell us about your child/dependent's medical and dental history so that we can serve you and your child/dependent as effectively as possible. Your information is being stored securely.
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  • Patient Info

  • Patient Biological Sex*

  • Guardian Info

  • NOTICE

    Please ensure you have been given the correct form!

    This form is intended for use by adults, on behalf of their child/dependent only. If you need the form for yourself, please contact the Cobourg FDC Office at (905) 372-7400.

  • General Health

  • Overall, would you consider the patient to be in good health?*
  • Within the past year, have there been any changes in the patient's general health?*
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  • Is the patient currently under the care of a physician due to a specific condition?*
  • Has the patient been hospitalized for surgery or illness within the last five (5) years?*
  • Is the patient currently taking any prescription medications or supplements?*

  • Medical Conditions

  • Has the patient been treated for or told you have any of the following:*
  • Please select all that apply:
  • Has the patient been diagnosed with any other disease or condition not mentioned above?*
  • Is there anything else about the patient's health that we should be aware of?*
  • Would you or the patient like to speak to the Doctor privately about anything?*

  • Dental Info

  • Was the patient's last dental exam done at this office?*
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  • Was the patient's last cleaning done at this office?*
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  • Was the patient's last set of X-Rays done at this office?*
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  • How often does the patient brush their teeth?*
  • How often does the patient floss their teeth?*
  • How often did the patient see their previous dentist/hygienist?*
  • Have there been any cavities noted in the last year?*
  • Is the patient currently receiving orthodontic treatment?*
  • Has the patient ever had any orthodontic treatment?*
  • Has the patient ever had any protective sealants placed on their teeth?*
  • Has the patient ever been suggested to wear a space maintainer?*
  • Has anyone in the patient's family ever had to wear orthodontics?*
  • Has the patient ever had any injuries to their teeth or jaw?*
  • Has the patient ever had any baby or permanent teeth extracted?*
  • Is the patient in any discomfort?*
  • How often does the patient consume sweets such as candy, pop, and gum?*
  • Does the patient receive fluoride?*

  • Final Page

  • Authorization

  • I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to the patient's health.

    I authorize the diagnosis of the patient's dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

    I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practicioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice and for it to be applied directly to any outstanding balance on my account.

    I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agreeto be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

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  • FOR OFFICE USE ONLY

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