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Medical Update Child Form

Child’s First Name *

Child’s Last Name *

Date of Birth *

Gender *

Male
Female
Other

Preferred Pronoun *

Child’s Physician/Pediatrician *

Physician’s Phone Number *

Is your child in good health? *

Is your child presently under the care of a physician for any medical reason? *

Explanation of the medical reason that your child is under care: *

Has your child ever been hospitalized or had surgery? *

Please provide details of the reason of hospitalization or previous surgery, including date and location. *

Is there a history of problems with sedation and/or anesthesia? *

Please give more details regarding any history of problems with sedation and/or anesthesia *

Is your child currently taking any medications? *

Please list any medications that your child currently taking. *

Are there any allergies or reactions? *

If yes, a list of allergies will appear. Check any applicable allergie(s)

Please list foods your child is allergic to *

Other allergies? Please list *

Have you ever been diagnosed as having any conditions? *

If yes, a list of conditions will appear. Check any applicable condition(s)

Other conditions? Please list *

I give consent to the Kids & Teens Dental to text and email office correspondence including, appointment reminders, account statements and general practice information. *

The permission of parent or guardian is necessary for dental treatment of a minor. *

I understand that all the above information I have given is correct and accurate; that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

Parent name *

Signature *

Relationship to Child *

Date *

Notice *

Signature code *

Message

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Monday to Thursday:
7:45 am – 4:30 pm

Friday:
7:50 am – 2:00 pm

Medical Update Child Form

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