For Office Use Only

Insurance/ID: ______

Medical History Update

Patient Name: ______Today’s Date: ______

______

Address Zip Code

______

Phone 2nd Phone

DOES YOUR CHILD HAVE A HISTORY OF ANY OF THE FOLLOWING: (CIRCLE)

Nursing/Bottle Habits Thumb/Finger Sucking

Pacifier Dental Grinding

Is your child currently under a physician’s care now? ______If yes, why? ______

______

Child’s Physician name: ______

______

Address Phone #

*Has your child ever been hospitalized or had a major operation? If yes, explain.

______

*Is your child currently taking any medications? If yes, what?

______

*Is your child allergic to any medications or substances? Please circle ALL that apply:

Aspirin Penicillin Latex Dyes Foods Pollutants Metals/Acrylics

OTHER: ______

*Has any member of the family, including your child, ever had a problem with general anesthesia?

______

*Are antibiotics necessary for dental work because of a heart murmur, heart defect, prosthesis or other medical reason? ______

DOES YOUR CHILD NOW HAVE OR HAS EVER HAD ANY OF THE FOLLOWING: PLEASE CHECK ALL THAT APPLY.

__Aids/HIV __Cerebral Palsy __Excessive Gagging __Leukemia

__Anemia __Chemotherapy __Fainting/Dizziness __Mental Disability __Asthma __Child Abuse __Fever Blisters __Orthopedic Problems __Autism __Chronic Adenoid/ __Growth Problems __Psychiatric Care

__Birth Defects Tonsil Problems __Heart Surgery __Sickle Cell Anemia

__Bladder Conditions __Cleft Lip/Palate __Headaches __Tuberculosis __Blood Disease __Convulsions/Seizures __Heart Murmur __Tumors or Growths

__Blood Transfusions __Developmentally Delayed __Hemophilia __Other:______

__Bone/Joint Problems __Diabetes __Hepatitis/Liver Disease ______

__Brain Injury __Drug Addiction __High Blood Pressure

__Bruising Easily __Emotional Disturbance __Hyperactivity/ADD

__Cancer __Excessive Bleeding __Kidney Disease Dr. Initials: ______

No-Show Cancellation Policy

THERE IS A $25 FEE FOR THE FOLLOWING:

1)  $25 fee applies if you do not cancel your appointment within 24 hours of scheduled time you are considered a no-show

2)  $25 fee applies if you do not show to your appointment you are considered a no-show

ABC Dental and Happy Smiles reserve the right to hold each patient accountable for the appointments they make, to notify the patient’s insurance plan of any missed appointments without 24 hours’ notice, and to charge patients for these missed appointments. If you miss scheduled appointments, the state reserves the right to terminate your Medicaid coverage.

If you have a change of phone number or address, it is your responsibility to contact us so we can remind you of future appointments.

We will call you to confirm your appointment. If we are unable to reach you, we reserves the right to give your appointment to other patients. By signing below you understand that you must confirm appointments and show up to those scheduled appointments to avoid being charged a $25 fee.

Name of Patient: ______

Patient’s Social Security #:______

Best Phone # to Confirm Appointments: ______

Signature of Parent or Guardian: ______