www.dentistryatlasalle.com - CHILDREN'S MEDICAL HISTORY FORM

CHILDREN'S MEDICAL HISTORY FORM
In order to render optimum health care service, it is necessary to become acquainted with the vital information related to each patient. Of course, all information is strictly confidential. Although some questions may seem unimportant at the moment, they may be vital in case of emergency. Therefore PLEASE ANSWER EVERY QUESTION. Please feel free to ask the receptionist for help in completing this form.
PERSONAL INFORMATION
Date

MonthDayYear
Date
Child’s Full Name

First NameLast Name
Nickname
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Age
Preferred Title
If "Other" Please Explain
Gender / Title
Birth Date

MonthDayYear
Date
School
Grade
Whom may we thank for referring you?
Parent/Guardian Name
Occupation/Employed by
Bus. Phone

Area CodePhone Number
Parent/Guardian Name
Occupation/Employed by
Bus. Phone

Area CodePhone Number
Do we need to send the insurance claims on your behalf?
Dental Ins. Co.
% covered
Group No.
Cert. or ID No.
Name of parent responsible for account
MEDICAL HISTORY
Child’s Physician
Phone Number

Area CodePhone Number
Is child now under the care of a physician?
If so, explain
Has child ever had any serious illness or been treated in the hospital?
If so, explain
Is child now taking any medicine?
What
Is child allergic to any medicine or food?
List
Has child ever had any unfavourable reaction to any previous medical or dental care?
Has child ever had any of the following conditions? (please ✓ any that apply)

Other
9 Out of 10 children suffer with these symptoms (please ✓ any that apply)

Other
DENTAL HISTORY
Has child had previous dental care?
If so, how long ago?
Has child ever had an accident, injury or surgery about the mouth?
If yes, describe
Has child ever had an unpleasant experience associated with a dental visit?
If yes, describe
Is the child particularly nervous about visiting the dentist?
Have child’s teeth ever been treated with decay-preventing Fluoride?
Has child ever had Orthodontic treatment?
Does child have any oral habits such as:

Other
Is there a family history of:
How often does your child brush his or her teeth?
Additional Information
AUTHORIZATION
I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical and dental histories are correct to the best of my knowledge. I understand that my dental insurance (if insured) is a contract between the insurance carrier and me and not between the insurance carrier and the dentist and that I am still responsible for all the dental fees. I understand that I will be charged for all dental treatment and that any payments received by the Dental Office from my insurance company will be credited to my account or refunded to me if I have paid the dental fees incurred.
PARENT’S CONSENT FOR CHILDREN UNDER 18
I hereby consent to the performing of the Dental and Oral Surgery procedures necessary or advisable for my children, including the use of Local Anesthesia and/or Relative Analgesia, as indicated, and I accept responsibility for the fee.
Parent’s Signature
Parent's Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

CHILDREN'S MEDICAL HISTORY FORM

PERSONAL INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

AUTHORIZATION

PARENT’S CONSENT FOR CHILDREN UNDER 18