6 Month Update Sheet

The Pediatric Dentists 6 month Update for Minor Children

CHILDS NAME*

AGE*

Have there been any changes in your child’s health since the last examination?*

YesNo

Is your child taking any medications?*

YesNo

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

YesNo

Please list changes in health, medication (w/ approx. start date), &/or injuries:

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

YesNo

Please explain

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

YesNo

Reason for visit

Name of office Dentist

Were any x-rays taken?

YesNo

Any Dental Insurance changes?*

YesNo

Subscriber Name

Subscriber DOB

New Insurance Name

Subscriber ID

Group

Group Plan/Employer

Check if applicable

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

Any employment changes?*

YesNo

Name of Parent/Guardian

New Place of Employment

Occupation

Are there any changes in your address(s) or phone number(s)?*

YesNo

Address

Phone

Parent/Guardian Name

Phone

Parent/Guardian Name

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 Address

example@example.com

Name of ParentGuardian for email

First NameLast Name

Date of birth ParentGuardian named above

Date

SIGNATURE*

RELATIONSHIP*

Print Name*

DATE*

Date

COMMENTS