Patient History Form

Date

Child's Name

Age

Date of Birth

Gender

Weight

What other children in your family have we seen?

Who referred your child to our office?

Pediatrician (physician)

II. Child's Dental

Has child had an unfavorable dental experiences?

YesNo

Has child had any injuries to the mouth or teeth?

YesNo

Does child have a toothache now?

YesNo

Does child have any mouth habits? (thumbsucking, pacifier, etc.)

YesNo

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.

I agree

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

MarriedSeparatedDivorcedSingle

Address

City

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

DOB

Social Security #

Relationship

Dental Insurance Company’s Name

Employer

Group #

Phone

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.

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