Medical History

Has this patient or any other family members been a patient of PDAA previously?^*

YesNo

Patient First Name^*

Patient Last Name^*

Gender^*

MaleFemale

Age^*

Date of Birth^*

Parent Name^*

Child's Height (if known)

Child's Weight^*

Home Phone

Work Phone

Cell Phone^*

Dentist's Name^*

Dentist's Location (Search by Name or Location)

Does your child take any medications?^*	YesNo
Does anyone smoke in your child’s home?^*	YesNo

Allergies^*	YesNo
Recent cold, cough or reactive airway^*	YesNo
Snoring, asthma or breathing problems^*	YesNo
Heart trouble, murmur, or heart surgery^*	YesNo
Surgery or hospitalizations^*	YesNo
Problems or complications with anesthesia^*	YesNo
Cerebral palsy, Epilepsy, Seizures or Fainting^*	YesNo
Developmental delay, Autism or ADHD^*	YesNo
Any other medical conditions?^*	YesNo

I have received the IV Sedation Information papers.^*

YesNo

How many minutes is your drive from home to the dental office?^*

Email^*

If you have any questions, please contact our billing office:

Email: billing@pediatricsedation.com

P.O. Box 2080

Palm Harbor, FL 34682-2080

Phone: 813-545-9924

Fax: 866-773-3520

Pediatric Anesthesia for Pediatric Dentistry