Patient Update 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

Previous Visit

Contact Information

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Parent/Legal Guardian's Name(s)

Medical Information

Are there any changes in the patient's health?

Yes

If so, please specify

Pediatrician's Name

Pediatrician's Phone Number

Dental History

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

Yes

Has your child had a toothache recently?

Yes

If yes, please explain

Does your child have any of the following habits?

Finger Sucking

Pacifier

Teeth Grinding

None

What type of water does your child drink?

Tap

Fridge

Bottle

Brita

Pur

Other

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

Yes

If yes, please explain

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

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.

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