Patient History Form

Patient History Form

Child's Name
Date of Birth
What other children in your family have we seen?
Who referred your child to our office?
Pediatrician (physician)

I. Child's Medical History

Does your child have any known physical disorder?
Does your child have any allergies (penicillin, asthma, etc.)?
If yes, what allergies?
Is your child receiving any medications?
If yes, what medications?
Has your child had any history of or difficulty with any of the following?:
Bladder Disease
Blood Disorders
Cerebral Palsy
Hearing/Speech Disorder
Heart Disorders
Kidney Disorders
Liver Disease
Lung Disease
Mental Retardation
Rheumatic Fever
Sinus Problems
Thyroid Disorders
Vision Disorders
HIV Positive

II. Child's Dental

Has child had an unfavorable dental experiences?
Has child had any injuries to the mouth or teeth?
Does child have a toothache now?
Does child have any mouth habits? (thumbsucking, pacifier, etc.)
Last dental examination/x-rays
Please identity any dental or medical problem of special concern or provide any other information which you think might be important in the care of your child.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status.

III. General Information

Parent or Guardian responsible for this account
Father's Full Name
Birth Date
Social Security
Contact Number
Mother's Full Name
Birth Date
Social Security
Contact Number
In case of emergency whom may we contact? (Name, Relationship, Phone)
List other names to whom we may release information

​​​​​​​Place of Employment and Occupation

Father's Work
Work Phone
Mother's Work
Work Phone

​​​​​​​Dental Insurance Information:

Policy Holder’s Name
Social Security #
Dental Insurance Company’s Name
Group #

All fees for services rendered are payable at the conclusion of each appointment unless other financial arrangements have been made. I agree to be responsible for payment of all services rendered for this child. If applicable I authorize my Insurance Company to pay directly to Dr. Morrow, Dr. Jamison and/or Dr. Beville. In understand that my dental insurance carrier may pay less than the actual bill for services and that I am responsible for the balance.

IV. Care of Parents:

At the first visit the teeth are cleaned then x-rayed for children over 3 years of age. If the child is suffering from a toothache, emergency treatment will be provided. No fillings or extractions will be done on the child’s first visit. An account of the services to be rendered and cost of the complete case will be given to the parent before any treatment is begun.

In providing dental care, we will treat your child as we would our own. Numbing agents and dental gas are used routinely to help overcome the feat of dental care. Dentistry is an important health service for your child, and we will attempt to provide your child a satisfying experience in our office.

V. Consent for treatment of a minor:

The undersigned hereby authorizes Dr. Morrow, Dr. Jamison and/or Dr. Beville to perform the examination including x-rays, and after explanation, all forms of treatment, medication, and therapy indicated for the dental care of the above named child. This consent shall remain in force and effect until cancelled by either party.