MEDICAL / DENTAL HISTORY FORM – PEDODONTIC-CHILD



YesNo

Primary Insurance

Secondary Insurance


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo
Hear Murmur
Joint Replacement
Osteoporosis
Rheumatic Fever
Asthma
Hepatitis A/B
Thyroid Disease
Mental Illness
AIDS/HIV
Heart Attack
Stroke
Kidney Disease
Liver Disease
Drug/Alcohol Abuse
Cancer
Jaundice
Epilepsy
Arthritis
Radiation Therapy
Steroid Therapy
Diabetes
High Blood Pressure
Artificial Joint Replacement


YesNo

Dental History


YesNo

YesNo

YesNo

YesNo
Cold
Hot
Sweet
Biting

YesNo

YesNo

YesNo

PATIENT CERTIFICATION AND CONSENT

I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.

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SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)

To be signed at your appointment