Medical-Dental History

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Medical-Dental History
Personal History
All of the information which you provided on this form will be held in the strictest confidence. Although some
questions may seem unimportant at the time, they may be vital in an emergency situation. Please answer each
question and ask if you need assistance completing the form.
Patients Name:________________________________________________
Sex: M F
Parents / Guardian:___________________________________________________________________
Date of Birth: __________________________
BC Care Card: ____________________________
Mailing Address:_____________________________________________________________________
Home Phone: ______________________________ Cell Phone:________________________________
E-Mail:_____________________________________________________________________________
Purpose of Visit:______________________________________________________________________
Family Dentist:____________________________
Medical Doctor: ___________________________
Referred by:_________________________________________________________________________
I authorize the doctor to perform diagnostic procedures and treatment as may be necessary for
proper dental care.
I authorize the release of information concerning my child’s health care, advice, and treatment
provided for the purpose of evaluating and administering claims for insurance benefits.
I understand that my dental insurance carrier or payer of my dental benefits may pay less than the
actual fee for services. I understand that I am financially responsible for payment in full on all
accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to
be responsible for payment of services provided.
Parent’s Signature:________________________________
Date:_______________________
Dentist’s Signature: _______________________________ Date: _______________________

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