Consent for Dental Care Authorization for Guardian / Non-Parent

Health History Update Form

Patient Name*

Has your child ever had any of the following conditions?*

Abnormal Bleeding
Auto Immune Disease
Developmental Delays/Disabilities
Kidney/Liver Conditions
ADD/ADHD
Asthma
Diabetes
Pregnancy
Allergies to Any Drugs
Autism Spectrum Disorder
Hearing Impairment
Reflux/GI Problems
Allergies to Latex Products
Cancer
Hemophilia/Blood Disorders
Rheumatic/Scarlet Fever
Any Hospital Stays
Cardiac (Heart Conditions)
Hepatitis
Seizures
Any Operations
Congenital Birth Defects
HIV + / AIDS
Tuberculosis
None of the Above

Is your child up to date on immunizations against childhood disease?*

Yes
No

If you checked any of the above medical conditions, or if you would like to discuss any other medical conditions your child has had, please explain below.

List all drugs your child is currently taking (or write NONE).*

List all allergies your child currently has (or write NONE).*

Signature

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need.

Signature of Parent or Legal Guardian*

(Please use your mouse or finger on a touchscreen to sign in the box.)

Typed Name of Parent or Legal Guardian*

Relationship to Patient*

Date*

Health History Update Form

Signature

Looking To Get A Healthy Smile For Your Kid?