Minor Welcome & Medical History Form

Welcome Form

Primary Residence

Parent/Guardian's Information

Emergency Contact

Secondary Dental Insurance Information

Getting to Know You

At Your Child's Visit

We invite you to stay with your child during his or her first visit and the initial examination; however, we want to give your child our full attention and have his or hers as well, so we ask that parents/legal guardians act as “silent observers” during the visit. Cooperation and trust must be established between the doctor and your child. This allows the doctor and staff to communicate with your child directly without distractions or safety concerns. Due to limited space, we ask that one parent accompany the child back and all siblings remain in the waiting area with a responsible adult. If no adult is available, we will bring the child back on their own and consult with the parent after our exam. There may be times when a child’s experience is enhanced by a parent’s absence, in which case we may ask the parent to wait outside in order to facilitate a more direct line of communication between the doctor and the child. Our goal is to make your child’s dental visit a safe and positive one. We thank you for your understanding and cooperation.

Consent for Treatment

I certify that the above information is complete and accurate to the best of my knowledge. I hereby authorize MI Smiles Dental and staff to take x-rays, photos, and other diagnostic aids as deemed appropriate by the Doctor to make a thorough diagnosis of my child’s needs. I authorize MI Smiles Dental to use my photographs and x-rays for research, marketing, education, or publication in professional journals. I fully understand that using anesthetic agents embodies certain risks. I understand I may ask for complete recital of any complications. I have received a copy of this office’s HIPAA policy or had the opportunity to do so. Lastly, I agree to be responsible for payment of services rendered on my child. I understand payment is due at time of service unless other arrangements have been made. If payments are not paid by agreed dates, I understand a 12% finance charge will be added on my account.

Medical History Form

Has Your Child Ever Had Any Of The Following Conditions:

Allergies:

Medical Questionnaire:

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. If a medical emergency arises in the office, a complete medical history is needed to provide you with the best care and efficiency. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or 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.