Child's Home Address
Who is responsible for making appointment?
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.
Your information will be encrypted.