Health History Form

Parent/Legal Guardian's Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Preferred Name

Gender

Date of Birth

Who is accompanying the child today?

Full Name

Relationship

Are you the legal guardian?

Yes

Home Address

City

State

Zip

How did you hear about our office?

Pediatrician's Name

Pediatrician's Phone Number

Pharmacy's Name

Pharmacy's Phone Number

Mother's Information

Full Name

Date of Birth

Phone Number

Home Address (if different from child's home address)

City

State

Zip

Father's Information

Full Name

Date of Birth

Phone Number

Home Address (if different from child's home address)

City

State

Zip

Health History

Does your child have any medical conditions or disabilities?

Yes

If yes, please list

Have you ever been told your child needs antibiotics before a dental visit?

Yes

Has your child ever had heart or cardiac problems?

Yes

Has your child had any surgeries or hospital visits?

Yes

If yes, please list

Does your child take any medications on a daily basis?

Yes

If yes, please list

Does your child have any food or medication allergies?

Yes

If yes, please list

Is your child allergic to latex?

Yes

Does your child have asthma or reactive airway disease?

Yes

What asthma medications were used last and when?

Please select all the conditions your child currently has, or HAS HAD in the past.

Heart Murmur

Cleft Lip/Palate

Tuberculosis

Hepatitis

Seizures

Congenital Birth Defect

Hearing/Visually Impaired

Rheumatic Fever

Diabetes

Developmental Delay/CP

Eczema

Hemophilia/Blood Disorder

HIV/AIDS

Ports/Catheters

Anemia/Sickle Cell

Ear Problems

Autism/PDD

Nervous Disorder

Liver/Kidney Disorders

ADD/ADHD

Cancer

Stomach/Digestive Problems

None

Does your child have any physical or mental disabilities or speech problems?

Yes

If yes, please explain

Dental History

What is the reason for your visit?

Is this your child's first visit to the dentist?

Yes

If not, approximately how long since your last dental visit?

Previous Dentist's Name

Has your child ever had a negative dental experience in the past?

Yes

Is there anything else about your child that you think we should know in order to better treat their dental needs?

Does your child have any of the following habits?

Finger Sucking

Pacifier

Teeth Grinding

None

Has your child ever had any injuries to the jaw, head, mouth, or teeth?

Yes

If yes, please explain

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I acknowledge that the above information is correct and grant permission to provide my child’s dental and related medical/surgical treatment as deemed necessary, utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete their treatment.

If there is a change in my child’s health, allergy or medication history, I will inform the dentist & staff immediately prior to any future appointments.

Name of Parent/Legal Guardian

Signature of Parent/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

HIPAA Consent Form

General Information

Patient Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Acknowledgment

By typing my name below, I acknowledge that I have reviewed both "Informed Consent for Dental Treatment" and the "Notice of Privacy Practices".

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Appointment Agreement

We reserve time in our schedule, especially for your child. In consideration of others, we require at least 2 business days' notice for any changes to appointments. We understand that there are circumstances that may prevent you from keeping your child's appointment; however, by providing us with as much notice as possible, we may be able to contact another child who requires care.

Changes to appointments with less than 2 business days' notice does not allow us enough time to schedule another patient in need of treatment.

You will receive notification by email/text for missed appointments without proper notification given. After two missed appointments without proper notification you will be placed on a "same day appointment" list. On a day that you feel it is convenient to bring your child in, call our office and, if time allows, we will place them in our schedule.

Parents/patients that are running late are asked to call the office as soon as possible to determine if the office will still be able to keep their appointment. Please call during regular business hours and speak with a team member if you need to make a change.

In consideration of other patients, your child's appointment may be rescheduled if you are more than 10 minutes late for your scheduled appointment time.

Appointments changed with less than 2 business days' notice that are scheduled on a school holiday, before or after school time will not be rescheduled on another school holiday, before or after school appointment time.

We greatly appreciate your cooperation in helping us provide excellent care to your family. Please sign below that you have read and acknowledge the above information provided to you.

Patient Name

Parent/Guardian Name

Parent/Guardian Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue