REGISTRATION AND HEALTH UPDATE
Please answer the following questions:
1. Has your child seen their physician since your last visit? Yes__ No __
If so why? __________________________________________________________________
2. Does your child have any sleeping, snoring, or breathing issues? Yes__ No __
If so, what? _
3. Change in medical history? Any Hospitalizations or Surgeries? Yes__ No__
If so, how/what? _____________________________________________________________
4. Is your child currently taking any medications? Yes__ No _
If so, what and why?
5. Has your child received all routine vaccinations or any injections? Yes__ No _
If so, what? _________________________________________________________________
6. Any injury to the head or neck in the last six months? Yes__ No__
If so, what? _________________________________________________________________
7. Any dental or medical problems that you are aware of? Yes__ No__
If so, what? _________________________________________________________________
8. Does your child need a new fluoride vitamin prescription? Yes__ No__
9. What school does your child attend? _____________
10. What is your relationship with the patient? _____________
Did your dental insurance Change since your last visit? If so please provide info below:
Kidzdent follows Federal and State Law by complying with HIPPA standards. Our Notice of Policy Practices is available to you at your request.
I certify that I have read and understood the above and I understand that the information that I have given is correct to the best of my knowledge. I
will not hold KidZdent or any member of the staff responsible for any errors or omissions I may have made in the completion of this form. I also
authorize the Doctor and staff of KidZdent to perform the necessary dental services they have explained to me.
Parent's signature ___________________________________ Date_________________
Child’s Name:
Parent’s / Guardian Name:
Address:
Parent’s Email:
Mom’s Cell #
Dad’s Cell #
Medical alerts currently on file:
Comments:
Member Name_______________________________ DOB____/ ____ /____
Employer
Carrier Name & Address__________________________________________
Group#____________ I.D#___________________ SS#
Date of Birth:
Patient Email:
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