Update Child Information
Name
Last Name
First Name
MI
Nickname
Birth Date
-
Month
-
Day
Year
Date
Age
SS#
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone#
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
School
Grade
Interests/Hobbies/Sports
Patient Information
Mother's Name
Last Name
First Name
MI
Address(If Different From Patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's SS#
Birth Date
-
Month
-
Day
Year
Date
Home#
Please enter a valid phone number.
Format: (000) 000-0000.
WK#
Please enter a valid phone number.
Format: (000) 000-0000.
ext
Mother's Employer
How long at job?
Job Title
Father's Name
Last Name
First Name
MI
Address (If Different From Patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's SS#
Birth Date
-
Month
-
Day
Year
Date
Home#
Please enter a valid phone number.
Format: (000) 000-0000.
Wk#
Please enter a valid phone number.
Format: (000) 000-0000.
ext
Father's Employer
How long at job?
Job Title
Dental Insurance Information
Insured's Name
Relation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Birth date
-
Month
-
Day
Year
Date
Insured's SS#
Insured's Employer
Insurance Co. Name
Medical History
Does child have a personal physician?
Yes
No
Physician's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone#
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last visit
-
Month
-
Day
Year
Date
Please describe child's current physical health
Good
Fair
Poor
Is child currently under the care of physician?
Yes
No
If yes, for what conditions?
Has child ever responded adversely to medical treatment?
Is child taking any medication at this time?
Yes
No
If yes, Please list
Does child have any drug allergies or has ever had an adverse reaction to any medication?
Yes
No
If so, list names of medications
Is there anything else we should know about your child's medical history?
Yes
No
If so, Explain
Are child immunizations current?
Yes
No
Does child have or ever had any of the following?(Check boxes that apply to child)
A.I.D.S./HIV
ADD/ADHD
Allergies to Anesthetics
Allergies to Latex
Allergies to Medicines
Artificial Heart Valves
Artificial Joints
Asthma
Blood Disease
Cancer
Chemical Dependency
Diabetes
Epilepsy
General Allergies
Hearing Impairment
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
Jaundice
Kidney /Liver Problems
Liver Disease
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Sickle Cell Disease/Traits
Sinus Problems
Special Diet
Tuberculosis (TB)
Dental Insurance Information
Insured's Name:
Relation:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured's Birth date:
-
Month
-
Day
Year
Date
Insured's SS#:
Insured's Employer:
Insurance Co.Name:
Parent Consent & Authorization
I affirm that the above information I have given is correct to the best of my knowledge
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: