Kids Dentist East Cobb

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  • 770-973-7687
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Appointment

    Dental/Medical History



    Your child's health, as well as any medications which your child takes, can have an
    interrelationship with the dental care you child receives.
    Please answer each
    question
    completely.



    Does your child:

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No


    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
    No

    Yes
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    Yes
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    Yes
    No

    Yes
    No

    Yes
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    Yes
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    Yes
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    Yes
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    Yes
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    Yes
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    Yes
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    Yes
    No

    Yes
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    Yes
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    Yes
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    Yes
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    Yes
    No

    Yes
    No

    Yes
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    Yes
    No











    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can put my child's health at risk, and that it is my responsibility to inform the dental office of any changes in my child's medical status.

    I authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information, including the diagnosis and the records of treatment or examination rendered to my child during the period of such care, to third-party payers and/or other health practitioners as necessary.

    I further acknowledge the receipt of the Dental Materials Fact Sheet and HIPAA Privacy Form.