"Consent Forms for Dentist"
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_________________________