Update Form

Lauren L. Gutenberg, DDS, MSD & Associates

6 Month Update for Minor Children

Child's Name

Child's Age

Have there been any changes in your child's health since the last examination

Yes No

Is your child taking any medications

Yes No

Has there been any injury to teeth, head, or neck recently?

Yes No

Please list any changes in health, medication (w/ approx. start date, and/or in juries)

Is there any condition or problem you wish to bring to our attention

Yes No

If so, please explain

Has your child recently had any oral surgery, orthodontics, or visited any other dental office in the past 6 months?

Yes No

Name of Office/Dentist

Reason for visit

Were any X-Rays taken?

Yes No

Any Dental Insurance Changes?

Yes No

Subscriber Name

Subscriber DOB

New Insurance Name

Subscriber ID

Group #

Group Plan/Employer

Paying out of pocket

My child is no longer covered under a dental insurance plan. I will be paying out of pocket and agree to make all payments (unless prior arrangements have been made) at the time services are rendered per office policy

Any Employment Changes?

Yes No

Name of Parent/Guardian

New Place of Employment

Occupation

Is there a change in your address(s) phone numbers)

Yes No

Address

Name of Parent/Guardian 1

Phone of Parent/Guardian 1

Name of Parent/Guardian 2

Phone of Parent/Guardian 2

We are in the process of moving our office completely digital: therefore, all billing will be electronic statements via email. If you could please provide the best email address to send any billing to, it would be much appreciated.

Email

example@example.com

Name of Parent/Guardian for Email

Date of Birth for Parent/Guardian named above:

Relationship

Signature *

Clear