Child Health History Update

Frankenmuth Family Dental

Please correct the errors described below.

To assist us in serving you, please complete the following confidential health questionnaire update form. The information provided is important to your child's dental health.

Your Child

Responsible for Scheduling Appointments

Responsible Party

Dental History

Medical History

Add additional condition

Add additional

Add additional

Add additional

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

Add additional parent/guardian

Your information will be encrypted.