Welcome to Our Office (Pediatrics - 17 & under)

 Did a Physician refer you?


 If referral is other than a Physician, please indicate:



General Medical Information


Are immunizations up to date?

Does child bruise easily?

Has child ever had cut such that bleeding was difficult to control?

Personal Medical History

Family History

Surgical History
    Do you have any objection to the use of blood products? (in the unlikely event they should become necessary)
Has your child or any family member had a reaction to any local or general anesthetic?

Does your child have any allergies to medication?

Allergic to Latex?
Allergic to X-Ray Dye?
    Does your child take any medications on a regular basis?
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