Pediatric and Adolescent Dentistry

MARTHA GARZON, D.M.D., M.S. Pediatric and Adolescent Dentistry 870 South Kelly Avenue Edmond, Oklahoma 73003 Phone:(405) 348- 5757 Fax: (405) 348-8221

PATIENT UPDATE SHEET Date: ______Patient’s Name: ______Has your address changed □Yes □ No If so, what is it? ______City: ______Zip: ______Telephone numbers where we can reach you during business hours: Home: ______Cell: ______Work: ______other: ______E-mail address: ______I consent to receive text message or e-mail appointment reminders. Signature: ______.

IF YOUR DENTAL INSURANCE HAS CHANGED, please give us the following information: Insurance Name ______Name of Insured: ______Relationship to patient: ______

To assist us in keeping your child’s medical history up to date, will you please answer the following questions: Did your child have any MEDICAL PROBLEMS OR CHANGES SINCE THE LAST APPOINTMENT? □ Yes □No; if so, please explain ______Is your child taking any MEDICATION at the present time? □Yes □ No If so, what medication and for what purpose? ______Has your child recently experienced any UNFAVORABLE REACTION to medicine, food, etc.? □Yes □ No; if so, what reaction? ______Has your child recently been to the ER or been hospitalized? □Yes □ No Date: ______Reason ______

Do you have any concerns about your child’s dental health? □Yes □ No If so, please explain ______

What would you suggest to improve our service in the future? ______I affirm that the information I have given is correct to the best of my knowledge, and is my responsibility to inform this practice of any changes in my child’s medical status. I accept responsibility for this account should the named responsible party fail or insurance be denied. I also agree to the diagnostic procedures necessary to make a thorough evaluation of my child’s dental needs.

Signature: ______□ Parent □ Guardian □ Other______