Patient History (child under 18 years old)

Please correct the errors described below.

1. Tell Us About Your Child

Child's Home Address

2. Who Is Accompanying The Child Today?

3. Mother's Information

4. Person Responsible For Account

Who is responsible for making appointment?

5. Primary Dental Insurance

Add Secondary Insurance?

6. Why did you bring the child to the dentist today?

7. Has the child ever had any of the following medial problems?

8. Does / did the child have any of the following habits?

Our office is HIPAA 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.

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

I authorize the dental staff to perform the necessary dental services my child may need.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


I verbally reviewed the medical / dental information above with the parent / guardian & patient named herein.

Medical History Update

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