SixOneSix Dentistry for Children

Form: *Established Patient 6 Month Health History Update

Patient Information

FIRST Name

LAST Name

MI

Medical

Does your child currently experience or have a history of any of the following?

Are there any other medical or genetic conditions not listed?

YES

NO

Does your child have any of the following allergies or food sensitivites?

Does your child have any allergies not listed?

YES

NO

Is your child currently taking any medication? (prescription or OTC)

YES

NO

Since we last saw your child, has your child had any surgeries or serious illness?

YES

NO

Are your child's vaccinations up to date?

YES

NO

Dental

Do you have any dental or orthodontic concerns for your child?

YES

NO

Is your child currently seeing an orthodontist? If yes, please name.

YES

NO

Does your child use a special fluoride? (Gel, rinse, toothpaste) If yes, please list.

YES

NO

Does your child drink city water?

YES

NO

How frequently is your child brushing and flossing?

AM Brushing

YES

NO

PM Brushing

YES

NO

Daily flossing

YES

NO

Do you help?

YES

NO

Any Changes to Your Address or Insurance?

Address:

Phone Number:

Email:

Dental Insurance Name:

Name of Insured:

Insurance ID/Social Security Number:

Employer:

Patient, Parent or Guardian

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. By signing you are: consenting to treatment of your child, authorizing release of information relating to dental claims, accepting responsibility for any and all costs of dental treatment and authorizing insurance payment to be made directly to SixOneSix Dentistry For Children.

Name

Form: *Established Patient 6 Month Health History Update

Patient Information

Medical

Does your child currently experience or have a history of any of the following?

Please choose YES or NO for all questions below.

Does your child have any of the following allergies or food sensitivites?

Please choose YES or NO for all questions below.

Dental

How frequently is your child brushing and flossing?

Please choose YES or NO for all questions below.

Any Changes to Your Address or Insurance?

Patient, Parent or Guardian

Sign Form