Recall Examination Information Update

Child Name ____________________________ Nick Name ______________________

Birth Date ________________ Child SS# ______-____-_______ Sex: Male or Female

Parents Name ________________ _____________ ____________________________

(First) (Middle) (Last)

Email Address ___________________________________________________________

Street Address ___________________________________________________________

Home Phone ____________________________ Cell Phone ______________________

Mother’s Employer ______________________________ Work Phone ______________

Father’s Employer _______________________________ Work Phone ______________

Name and Phone of Nearest Relative not Living with you ___________________________

Changes in Insurance Coverage ______________________________________________

To assist us in keeping your child’s medical history up to date, would you please answer the

following?

Has your child seen his/her doctor since your last visit? Yes or No. If so, what were they seen for?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Is your child taking any medication at the present time? Yes or No. If so, what is the medication(s)?

___________________________________________________________________________

___________________________________________________________________________

Has your child received any injections in the last year? Yes or No. If so, what were they for?

___________________________________________________________________________

___________________________________________________________________________

Any injuries to the head or neck in the last 6 months? Yes or No. If so, please describe.

___________________________________________________________________________

Are there any dental problems that you are aware of? Yes or No. If yes, please describe.

___________________________________________________________________________

___________________________________________________________________________

Are there any medically-related concerns or problems? Yes or No. If yes, please describe.

___________________________________________________________________________

___________________________________________________________________________

Parent Signature _______________________________________ Date __________________

Signature On File Card

Dental Plan Name: ____________________________________________________________

I hereby accept the foregoing treatment plan and authorize release of any information that is related

to this claim. I understand the portion of the Dentist’s charges covered under the dental care plan

named above will be paid direct to the dentist. I also understand that I ‘am personally responsible

for any portions of those charges that are not covered or paid by the plan.

Employee, Patient or Parent _____________________________________________________

(Signature and Date)