Medical History Update

Medical History Form

Patients Name

Date of Birth

IMPORTANT NOTICE: WE REQUIRE A PARENT OR LEGAL GUARDIAN BE PRESENT AT ALL APPOINTMENTS.
PLEASE NOTIFY THE FRONT DESK IF YOU ARE NOT THE PARENT OR LEGAL GUARDIAN OF THE PATIENT.

Has your child’s medical history changed since his/her last visit to this office?

Yes No

If YES, please explain:

Is your child currently taking any medications?

Yes No

If YES, please explain:

Does your child have any heart conditions?

Yes No

If YES, what conditions?

Does your child require antibiotic prophylaxis or premedication before any dental treatment?

Yes No

If YES, please explain:

Does your child have any allergies to food, latex, or any medications?

Yes No

If YES, please explain:

Do you have any concerns you would like us to pay close attention to at today’s visit?

Yes No

If YES, please explain:

Were there any changesin your address, phone number, or dental insurance?

Yes No

If you have n ew dental insurance that was not given to us prior to todays appointment time, please present it to the front desk and be aware that there will be a wait as we have to verify the new insurance policy.

If YES, please add them:

If you are the parent and do not currently receive our text or email reminders and would like to, please add them below (It can only go to one email/phone number):

Consent for Dental Treatment

I, undersigned pa rent/legal gua rdian, authorize Busciglio Smiles staff to examine this child, clean his/her teeth, perform necessary dental treatment, administer local anesthetics, administer medications, apply topical fluoride, obtain study models and other records necessa ry for an accurate diagnosis for my child. I further request a nd authorize the taking of dental radiographs (x -rays) as may be considered necessary by the doctor and staff to diagnose and/ or treat my child’s dental condition. I will allow photographs to be taken of my child and/ or my child’s teeth for diagnostic or educational purposes. I understand tha t dental treatment for my children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. We will provide an environment likely to help children learn to cooperate during treatment by using praise, explanation and demonstration of procedures and instruments, using variable voice tone, mouth props, nitrous oxide (laughing gas), or protective stabilization when necessary to promote cooperative behavior a nd a positive experience and to protect my child from potential injury. I understand the information tha t I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in my child’s medical status. I understand that I am responsible for the cost of these dental services at the time of the visit.

Signature of Parent or Legal Guardin

Relationship to Child

Date

Simply Smile & Stand Out

Medical History Form

Consent for Dental Treatment