Child Patient Form


Child Patient Information
 





Date of birth
 
 


 
 

 
 
 

 

Do you wish to receive appointment reminders?



 

Approximate date of last visit?
 
 


Responsible Party
 

 Parent/Guardian/Domestic Partner
 



Date of birth
 





 
 
 


Do you wish to receive appointment reminders?



 
 

Parent/Guardian/Domestic Partner
 




Date of birth
 






 
 
 


Do you wish to receive appointment reminders?



 
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Dental Insurance Information
 









Birth Date
 
 
 

 
 






Birth Date
 
 


 
 


Medical History
 








Medical History
 



Last Visit
 
 

 
 

Has the patient tonsils or adenoids been removed?



Has the patient experienced jaw joint pain/discomfort? (TMJ/TMD)?



Does the patient have missing or extra permanent teeth?



Has the patient had an injury to?




Does the patient have a history of eating disorders?



Does/has the patient had any of the following habits?








 

Is the child allergic to any of the following?









 
 


Emergency Contact
 




I understand that the information that I have provided is correct to the best of my knowledge, that it will be held to the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature:
Date: