Consent Forms for Dentist

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					                                        GIVE KIDS A SMILE!
                                HEALTH HISTORY AND CONSENT FORM


First Name_________________________ MI_________ Last Name_____________________

Date of Birth__________________________ Sex (Circle One)              M            F

Address_______________________________________________________________________
                       Street                         City                             ZIP Code

Phone________________________________ Emergency Phone_________________________

Does your child have or has your child had:
Asthma               Y       N                               Congenital Heart Disease         Y     N
Heart Murmur         Y       N                               Rheumatic Heart Disease          Y     N
Diabetes             Y       N                               Bleeding Problems                Y     N
Seizures             Y       N

Is your child taking any medications?    Y     N
If yes, what medications?_________________________________________________________

Does your child have any allergies?      Y     N
If yes, what allergies?____________________________________________________________

Has your child had any other serious illness or operation? Y  N
If yes, what illness or operation?___________________________________________________

Is there anything else we should know about the health of your child?______________________

______________________________________________________________________________

Who should we contact on the day of service to determine your child’s care?

Name (print)____________________________________             Phone________________________

I give consent for my child to receive an examination and treatment today as part of the preventive and
restorative dentistry program conducted by the “Give Kids a Smile!” program. I understand that my child’s
relationship with the dentist is limited to my child’s visit today. I understand that the dentist is not my child’s
dentist, and that my child is not his/her patient. I acknowledge that the dentist owes my child no duty to
examine or treat any dental condition that my child may have. I understand that if the dentist recommends
further dental diagnosis and/or treatment for my child, it is my responsibility to make an appointment with
another dentist and to make sure that my child receives such further care. I have received a copy of this form.
To the best of my knowledge, the medical history questions have been answered correctly and accurately. I
allow my child to receive local anesthetic (numbing of the teeth) if necessary.

Name of Parent/Guardian (printed)_________________________________________________

Signature________________________________________ Date_________________________

				
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