Tell Us About Your Child
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Who Is Accompanying the Child Today?

Mother’s Information
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Father’s Information
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Primary Dental Insurance
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Secondary Dental Insurance
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Dental History

Medical History
Plastic: Yes No Metals/Nickel: Yes No Latex: Yes No
Abnormal bleeding: Yes No ADD / ADHD: Yes No Allergies to any drugs: Yes No Any hospital stays: Yes No Any operations: Yes No Artificial Bones / Joints: Yes No Asthma: Yes No Cancer / Chemotherapy: Yes No Congenital Heart Defect: Yes No Convulsions / Epilepsy: Yes No Diabetes: Yes No Handicaps / Disabilities: Yes No Hearing Impairment: Yes No Heart Murmur: Yes No Hemophilia: Yes No Hepatitis: Yes No HIV+ / AIDS: Yes No Kidney / Liver Problems: Yes No Rheumatic / Scarlet Fever: Yes No Sickle Cell Disease: Yes No Tuberculosis (TB): Yes No
Lip Sucking / Biting: Yes No Nail Biting: Yes No Nursing Battle Habits: Yes No Thumb / Finger Sucking: Yes No

Our office is HPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


Neighbor or Relative not living with you

We'll have Consent for Treatment and HIPPA forms ready for you to sign when you come in to see us.