Home
About
Services
Patients
Testimonials
Blog
Contact
- Request an Appointment
(616) 447-7900

Home
About
Services
Patients
Testimonials
Blog
Contact
- Request an Appointment
(616) 447-7900

Home
About
Services
Patients
Testimonials
Blog
Contact
- Request an Appointment
(616) 447-7900

Information Update Paperwork

* indicates a required field

"*" indicates required fields

Step 1 of 2

50%

Health History Update

Patient Name*

Date*

MM slash DD slash YYYY

Have there been any changes to insurance, address, or phone number?

Yes

No

If so, provide:

Is your child in good health?

Yes

No

Name of Child's Physician

Date of last physical exam

MM slash DD slash YYYY

Has your child had any recent health problems or significant injuries?

Yes

No

If yes, please explain:

Has your child recently been hospitalized?

Yes

No

Please give reasons and dates:

Is your child allergic to anything?

Yes

No

If yes, please explain:

Is your child currently taking any medications?

Yes

No

Please give medication, does, and reason:

Do you have fluoride in your water?

Yes

No

If yes, please explain:

Is your child up to date on all vaccinations?

Yes

No

Please list:

Please check if your child has been treated for any of the following:

Heart disease

Heart murmur

Liver/GI disease

Kidney disease

Speech/hearing

Vision problems

Cancer/tumors

Anemia

Abuse

ADD/ADHD

Asthma

Cerebral Palsy

Tonsil/adenoid problems

Abnormal Bleeding

Spina Bifida

Diabets

Rheumatic Fever

Seizures

Congenital birth defects

Recurrent headaches

Blood disorder

TB

Arthritis

Mental delays

Snoring

Sickle Cell disease

HIV/AIDS

Hepatitis

Cleft lip/palate

Personality/social

Frequent infections

Autism

Emotional problems

Adverse Drug Reaction

Physical delays

Endocrine disorder

Other issues

Transfusions

Please list transfusion dates:

Please explain any items checked:

The following treatment has been recommended at this visit. Plese indicate your approval or refusal by marking "Yes" or "No."

Tx recommended at this recall:

BW PA FL PANO

Notes:

FLUORIDE/X-RAY APPROVAL

Bitewings:

Yes

No

PA/Pano:

Yes

No

Fluoride:

Yes

No

It is your responsibility to know your insurance benefits (if applicable). Your insurance is a contract between you and your insurance company. Our office is not responsible for knowing frequencies, coverage, and limitations.

Signature*

Date*

MM slash DD slash YYYY

Relationship to Patient

Provider Initials

Patient Information Request

Mother's Name

Birthdate

MM slash DD slash YYYY

Social Security #

Employer

Father's Name

Birthdate

MM slash DD slash YYYY

Social Security #

Employer

Primary Insurance

Subscriber's Name

Relationship to Patient

Birthdate

MM slash DD slash YYYY

Social Security #

Employer

ID Number

Name of Dental Insurance Carrier

Group Number

Additional Insurance

Subscriber's Name

Relationship to Patient

Birthdate

MM slash DD slash YYYY

Social Security #

Employer

ID Number

Name of Dental Insurance Carrier

Group Number

Signature

Date

MM slash DD slash YYYY

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Contact Us

3297 Eagle Run Drive NE
Grand Rapids, Michigan 49525

Phone: (616) 447-7900
Fax: (616) 447-7902

Mon – Thu:
7:30 am – 4:30 pm

Services

Teeth Cleanings

Resources

Accepted Insurance

New Patient Forms

Information Updates

© Pediatric Dentistry of Michigan, All Rights Reserved
Dental Digital Marketing by PMAX Dental