Capitol Kids Dentistry: Medical History Update Form

Capitol Kids Dentistry: Medical History Update Form
Megan Haggerty, DMD

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315 Leonardwood Dr, #5 Frankfort, KY 40601

(502) 699-2571
To assist us in keeping your child's medical history up-to-date, please answer the following:
Child's Name*

First NameLast Name
MaleFemale
Age
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work/Cell Phone
Please enter a valid phone number.
Email
example@example.com
School
Policy Holder's Name
Employer
Dental Insurance
Policy Holder's Date Of Birth

MonthDayYear
Date
Emergency Contact
Emergency Phone
Please enter a valid phone number.
Is your child having any dental problems? If yes, what?

NoYes
Has your child had a physical since your last visit? If yes, when?

NoYes
Has your child's medical history changed since your last visit? If yes, how?

NoYes
Is your child taking any medications at the present time? If yes, what?

NoYes
Has your child had any injuries to the face, head, or neck? If yes, when and where?

NoYes
Do you feel that you and your child are treated well in our office? If not, why?

NoYes
What do you like best about our office?
What would you suggest to improve our service in the future?
Type Electronically-Binding Signature:*
Date*

MonthDayYear
Date
Should be Empty: