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

Child's Name:

Age:

Parent's Name:

Relationship:

Address:

Billing Address (if different than above):

Home Phone:

Father's Work Phone:

Mother's Work Phone:

Any New Dental Insurance:

Address:

Policy Holder's Name:

Policy Holder's DOB:

Social Security No:

Cell Phone:

Employer:

Email:

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?

Yes No

if so, why:

2. Has your child's medical history changed since your last visit?

Yes No

if so how:

3. Is your child taking any medication at the present time?

Yes No

if so what and why:

4. Has your child received any injections within the last year?

Yes No

if so what:

5. Any injury to head or neck in last 6 months?

Yes No

if so, what? (ex. front teeth):

Cause of injury (ex. car accident, bike, door, etc.):

6. Any dental problems developed or developing that you are aware of?

Yes No

7. Other dental or medical related concerns or problems:

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?

Yes No

If not why:

2. What do you like most about your treatment in our office?:

3. What would you suggest to improve our service in the future?:

4. If your child has a very loose tooth, would you like us to remove it?

Yes No

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:

Cash

Check

Credit Card

CareCredit

Medicaid

Date:

Signed:

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.

Date:

Signature:

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