Medical History Update Form

Medical History Update Form

Medical History Update

Form Completed By:
Is your child currently seeing a specialist for ANY reason?
Is your child currently seeing another dentist/orthodontist?
* Is your child currently taking ANY medications?

Does your child currently have or had a history of any of the following?

* Drug Allergy
* Latex Allergy
* Anemia
* Cerebral Palsy
* Cancer
* Seasonal Allergies
* Asthma
* ADHD
* ADD
* Delayed Development
* Liver Disorder
* Immmune System
* Musculosketetal System
* Epilepsy/Seizures
* AIDS or HIV
* Sickle Cell Anemia
* Blood Disorder
* Arthritis
* Radiation Treatment
* Diabetes
* Kidney Disorder
* Hepatitis
* Mouth Breathing
* Grinding
* Thumb Sucking
* Snoring
* Does your child currently have a diagnosed Cardiac Condition or Active Heart Murmur that is currently being monitored by a Cardiologist?
* Does your child have any Drug or other Allergies?
* Do we have permission to take any necessary x-rays?

** Please note that x-rays may be recommended more frequently then your insurance plan will pay for. ALSO, in some cases if x-rays are denied by the parent and your insurance plan does cover them, your insurance plan may not pay for restorative treatment if it is needed.**

* Do we have permission to apply flouride treatment today?

** Please note that flouride may be recommended more frequently than your insurance plan will par for.**

48 Hour Illness Free Policy

For the health and safety of all our patients, Smiles by CDO has an automatic reschedule policy if your child in the past 48 hours has had fever, flu, strep throat, pink eye, fever blisters, vomiting, ring worm, hand/foot/mouth, or any other highly contagious condition. Please notify us immediately so we can reschedule your appointment.

* Illness Policy:

Parent/Guardian Signature

Please contact the office 2 hours prior to your appointment if you have any changes to your insurance. This will allow us to keep your appointments as efficient as possible.



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