Health/Dental History Update
(For CHECK-UP APPOINTMENTS ONLY)
First and Last Name of Child/Patient *
First and Last Name of Parent/Guardian *
Cell Phone Number of parent/guardian bringing child to the appointment *
Any changes to your address or email since your last visit? (Please list or type "No.") *
Any changes to your dental insurance since your last visit? (Yes or No - If yes, PLEASE LIST CHANGES)
Is your child experiencing any dental problems or do you have any specific questions or new information for the dentist? (Please list or type "No.") *
Does your child have a heart murmur or heart defect (Yes or No) *
Please list any medications, supplements, recent injuries, illnesses, or operations (or type "None") *
COVID-19 screening: Do you or your child currently have any of the following: Fever, cough, shortness of breath, sore throat, loss of smell and taste, congestion/runny nose, muscle aches, fatigue, nausea, diarrhea, dizziness, headache, chills or repeated shaking with chills? (If yes, please call the office to discuss further.) *
Have you or your child had close contact with someone confirmed or suspected of having the new coronavirus (COVID-19) within the past 14 days? (If yes, please call the office to discuss further.) *
By selecting "I accept," you are indicating that all the information on this form is true and accurate, to the best of your knowledge. *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy