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?

Is your child taking any medications?

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

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?

Please explain

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

Reason for visit

Name of office Dentist

Were any x-rays taken?

Any Dental Insurance changes?

Subscriber Name

Subscriber DOB

New Insurance Name

Subscriber ID

Group

Group Plan/Employer

Check if applicable

Any employment changes?

Name of Parent/Guardian

New Place of Employment

Occupation

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

Address

Phone

Format: (000) 000-0000.

Parent/Guardian Name

Phone

Format: (000) 000-0000.

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