UPDATED MEDICAL HISTORY
Point Loma Children's Dentistry
2445 Truxtun Road, Suite 106
San Diego, CA 92106
(619) 567-8977
Patient Name:
First Name
Middle Name
Last Name
Preferred Name:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
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Area Code
Phone Number
Mobile Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Ext Phone
Format: (000) 000-0000.
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AM/PM Option
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Any change in insurance information.
Yes
No
If yes please provide new information
Has your child medical history changed since your last visit
Yes
No
If yes please explain:
Does your child have allergies or sensitivities to any drugs or medications
Yes
No
If yes, please explain:
Allergies to latex rubber
Yes
No
Is your child taking any medications at present
Yes
No
if so what
Are there any concerns for your child's mouth at this time
Does your child have history of Tuberculosis
Yes
No
*
--By checking this box, I understand that the information I have given is to the best of my knowledge and that it will be held in the strictest of confidence. It is my responsibility to inform this office of any changes in my child's status
--I understand that I am financially responsible for all dental treatment that is provided to my child. I understand that my insurance carrier my pay less than the actual fee for the services provided to my child. I understand that I am responsible for all charges whether or not they are paid for by my insurance carrier. We must emphasize that as dental care providers, our relationship is with you and not your insurance company. Please understand that all charges are ultimately your responsibility from the date services are rendered. If insurance claims are denied or procedures are not covered, you are still financially responsible for the services provided.
--I have read this office's Financial Arrangement Policy
Responsible party signature
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Year
2 digit month, 2 digit day, 4 digit year
Date
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