Health History Update

Health History Update
Child’s Name
Child's Name
First
Middle
Last
Nickname
Gender
Medicaid or Texas CHIP
Home Address
Home Address
City
State/Province
Zip/Postal
Reason for today’s visit (check all that apply)
Does this person have legal custody of this child?

Medical History Update

Any changes in medical history or illnesses?
Is there any allergy to penicillin or other drugs?
Are there any other allergies?
Do you have any dental concerns?
Would you be interested in discussing straightening your teeth with clear aligners (Invisalign) today?

*Note: this would not be covered by your insurance*

Has this child had any treatment on any of the following?

Has this child ever been diagnosed as having any of the following conditions?

Services my child is scheduled to receive today:
I give my consent for my child to have a
(A separate consent form is required for fillings, crowns, sealants, extractions, etc)
The information I have given is correct to the best of my knowledge and I understand that it will be held in the strictest confidence. I understand that providing incorrect information can be dangerous to my child’s health. I understand it is my responsibility to inform this office of any changes in my child’s medical status.
I authorize the release of information to all of my insurance companies. I understand that I am responsible for all financial responsibilities.

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