6 Month Update Form
Date Of Birth
Has the patient had any hospitalizations, surgeries or serious illness since their last dental cleaning?
Has the patient had any accident involving teeth of face?
Has the patient developed a latex or other allergy since they were last in?
Please Explain Yes to any of the above:
Is the patient taking medication routinely?
If Doctors recommend, may we have your permission to take dental x-rays today for the patient?
Do you have any questions or concerns about the patient's dental care?
Does the patient participate in sports?
Which sports and is a mouthguard worn?
As a child is a minor, it is necessary to obtain permission from a parent or guardian before today's treatment. If you are 18+ years of age, you can complete your own forms. The signature of a parent or guardian or patient 18+ years of age affixed below authorizes the completion of all agreed upon dental treatment. This consent shall remain in full force and in effect until cancelled by either party. Furthermore, the undersigned agrees to be responsible for any bill incurred by this patient for dental treatment regardless of insurance coverage. I understand fulyl this consent and have no further questions.
Signature Legal Guardian/Patient 18+ years of age
Sign by Pad
Sign by Pad
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