JIM CONGLETON, D.D.S., MS • ROBERT HARRISON, D.M.D., M.S.D.
700 McCarthy Boulevard, New Bern, NC 28562
252-633-0424 • Fax: 252-638-6662
info@coastalpediatricdentistry.com
www.drjimc.com

Continual Health Status Report



To assist us in keeping your child's medical history up to date, would you please answer the following questions:

1. Has your child seen his/her physician since your last visit?
2. Has your child's medical history changed since your last visit?
3. Is your child taking any medication at the present time?   
4. Has your child received any injections within the last year?
5. Any injury to head or neck in last 6 months?
6. Any dental problems developed or developing that you are aware of?

In order to continue to provide the best possible care to your children, would you please offer your comments below:

1. Do you feel you and your child are well treated in our office?
4. If your child has a very loose tooth, would you like us to remove it?

Because your child is a minor, it becomes necessary that a signed permission is obtained from a parent or guardian before any dental services can be rendered.
Authorization is hereby granted for dental treatment. I will be responsible for any bill incurred on this child for dental treatment.
In an effort to reduce our billing costs so that we can keep your fees down, we require that all fees or estimated co-payments be made on the day of the appointment.

I will be paying today by:

AS OF AGE 15, MOST PATIENTS WILL BE REFERRED TO A GENERAL DENTIST

INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize Jim Congleton D.D.S., M.S. to furnish information to insurance carriers concerning my dependent's treatments and I hereby assign to the dentist all payments for his services rendered to my dependents. I understand that I am responsible for any amount not covered by insurance.

Please click on the human verification checkbox before submitting your form.