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6 Month Dental/Medical Update (Hermitage)
Patient First Name
*
Patient Last Name
*
Date of Birth
*
Address 1
*
Address 2
City
*
State
*
Postal Code
*
Home Phone
Work Phone
Cell Phone
Email Address
Dental Insurance Carrier
*
Subscriber Name
*
List authorized adults who can accompany & consent to your child’s dental treatment:
Is your child taking any medication?
*
Yes
No
If Yes, please list the medications:
List any drug allergies:
0/255 characters
Patient's Primary Physician
*
Primary Physician Phone Number
Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.
Medical Conditions
*
My child does not have any medical conditions.
Rheumatic Fever
Heart Condition
Heart Murmur
Speech Disorder
Hearing Disorder
Vision Disorder
Nerve Disorder
Bleeding Disorder
Kidney Problems
Gag Reflex
Asthma
Tuberculosis
Brain Injury
Sickle Cell Anemia
Epilepsy
Diabetes
Delayed Deve.
Hepatitis
Mental Disorder
HIV/AIDS
Emotional Disorder
Pregnancy
Autism
Head Lice
Poison Ivy/Oak
ADD/ADHD
Ringworm
Chicken Pox
Other
Other
If you have additional children under the same address and insurance provider, check below. If you have additional children with different information you will need to fill out a new form.
Additional Child (2):
YES! I have additional children for which this address and insurance provider apply.
Patient First Name
*
Patient Last Name
*
Date of Birth
*
Is your child taking any medication?
*
Yes
No
If Yes, please list the medications:
List any drug allergies:
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health?
*
Yes
No
If yes, please explain.
Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.
Medical Conditions
*
My child does not have any medical conditions.
Rheumatic Fever
Heart Condition
Heart Murmur
Speech Disorder
Hearing Disorder
Vision Disorder
Nerve Disorder
Bleeding Disorder
Kidney Problems
Gag Reflex
Asthma
Tuberculosis
Brain Injury
Sickle Cell Anemia
Epilepsy
Diabetes
Delayed Deve.
Hepatitis
Mental Disorder
HIV/AIDS
Emotional Disorder
Pregnancy
Autism
Head Lice
Poison Ivy/Oak
ADD/ADHD
Ringworm
Chicken Pox
Other
Other
Additional Child (3)
:
YES! I have additional children for which this address and insurance provider apply.
Patient First Name
*
Patient Last Name
*
Date of Birth
*
Is your child taking any medication?
*
Yes
No
If Yes, please list the medications:
List any drug allergies:
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health?
*
Yes
No
If yes, please explain.
Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.
Medical Conditions
*
My child does not have any medical conditions.
Rheumatic Fever
Heart Condition
Heart Murmur
Speech Disorder
Hearing Disorder
Vision Disorder
Nerve Disorder
Bleeding Disorder
Kidney Problems
Gag Reflex
Asthma
Tuberculosis
Brain Injury
Sickle Cell Anemia
Epilepsy
Diabetes
Delayed Deve.
Hepatitis
Mental Disorder
HIV/AIDS
Emotional Disorder
Pregnancy
Autism
Head Lice
Poison Ivy/Oak
ADD/ADHD
Ringworm
Chicken Pox
Other
Other
Additional Child (4):
YES! I have additional children for which this address and insurance provider apply.
Patient First Name
*
Patient Last Name
*
Date of Birth
*
Is your child taking any medication?
*
Yes
No
If Yes, please list the medications:
List any drug allergies:
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health?
*
Yes
No
Medical Conditions
*
My child does not have any medical conditions.
Rheumatic Fever
Heart Condition
Heart Murmur
Speech Disorder
Hearing Disorder
Vision Disorder
Nerve Disorder
Bleeding Disorder
Kidney Problems
Gag Reflex
Asthma
Tuberculosis
Brain Injury
Sickle Cell Anemia
Epilepsy
Diabetes
Delayed Deve.
Hepatitis
Mental Disorder
HIV/AIDS
Emotional Disorder
Pregnancy
Autism
Head Lice
Poison Ivy/Oak
ADD/ADHD
Ringworm
Chicken Pox
Other
Other
If yes, please explain.
Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.
If you have more than 4 children, please fill out another 6 month update once this form has been submitted.
I authorize and request my insurance company to pay directly to the dentist or dental group those insurance benefits otherwise payable to me. I agree to be responsible for payment of all services rendered on behalf of my dependents. I understand that I am to call 48 hours in advance to confirm my child’s dental appointment. Failure to call and confirm will result in cancellation of his/her appointment.
Parent/Guardian
*
clear
Date
*