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Stowe Dental Associates

Children’s Medical History Form

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Child's Information

Child's Name*

First Last

Date of Birth

MM slash DD slash YYYY

Sex*

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Name of School

Mother's Information

Name*

First Last

Address if different than Child's.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

MM slash DD slash YYYY

Cell Phone Number

Work Phone Number

Employer

Email*

Father's Information

Name*

First Last

Address if different than Child's.

Street Address Address Line 2 City State ZIP Code

Date of Birth

MM slash DD slash YYYY

Work Phone Number

Cell Phone Number

Employer

Email*

Who is responsible for payments?

Name*

First Last

Address and Phone Number if different from above.

Primary Dental Information

Insured Name

First Last

Relationship to Insured Name

Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Insurance Company

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Insurance Company Phone

Group Number

ID#

Secondary Dental Information

Insured Name

First Last

Relationship to Insured Name

Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Insurance Company

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Insurance Company Phone

Group Number

ID#

Additional Notes

Health Information

Your child’s overall health as well as any medications your child takes could have an important inter-relationship with the dental care your child receives. Please answer each of the following questions completely.

Health History

Has your child had COVID-19 Vaccination?*

Moderna

Pfizer

J&J

None

Has your child had any difficulty with previous visits?*

Yes

Comments

Has your child ever had any of the following:

Asthma

HIV/AIDS

Diabetes

Rheumatic Fever

Handicaps/Disabilities

Tuberculosis

Heart Murmur

Cancer/Hepatitis

Hemophilia

Allergies

Congenital Heart Defects

Convulsions/Epilepsy

Abnormal Bleeding

Covid-19

Persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Has your child ever taken Fen-Phen/Redux?*

Yes

Please explain any medical problems that your child has.

Child’s Habits

How often does your child brush?*

How often does your child floss?*

Date of last dental visit?*

Previous Dentist Name, Address & Phone Number

Child’s Physician

Address & Phone Number

Is your child’s water fluoridated?*

Yes

Does your child take fluoride supplements?*

Yes

Does your child:

Suck thumb/finger

Suck / bite lips

Bite / chew nails

Chew hard objects (pencils, etc)

Grind teeth

Clench jaws

Snore

Authorization & Release:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I authorize the dentist to release any information including records of any treatment or examination rendered to my child during the period of such dental care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient’s parent or guardian*

Date*

MM slash DD slash YYYY

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Name

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Office Hours

Monday – Thursday
8:00 AM – 4:30 PM

Stowe Dental Associates

Contact Us

We believe that excellent care begins with open communication.

If you need more information, have any questions, or want to schedule an appointment, please contact us!

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Full Name*

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 32 Mountain Road
PO Box 1543
Stowe, VT 05672

 DIRECTIONS

 802.253.7932

 info@stowedentalassociates.com

 Hours: Mon – Thurs: 8:00 AM – 4:30 PM