Child Health History Update

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

Child's Name

Nickname

Date of Birth

Address

City

State

Zip Code

Responsible for Scheduling Appointments

Name

Relationship

Social Security Number

Date of Birth

Email address

Home Phone

Cell Phone

Work Phone

Employer

Responsible Party

Same as Above

Name

Relationship

Social Security Number

Date of Birth

Email address

Home Phone

Cell Phone

Work Phone

Employer

Address (if different from child)

City

State

Zip Code

Dental History

How often does your child brush?

How often does your child floss?

Is your child's water fluoridated?

Yes No

Does your child take fluoride supplements?

Yes No

Does your child do any of the following? Please check all that apply.

Suck thumb/finger?

Suck/bite lip?

Bite/chew nails?

Chew hard objects? (pencils, etc.)

Clench jaw/grind teeth?

Complain of tooth pain?

Medical History

Child's Physician

Phone Number

For heart condition, please specify:

Add additional condition

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.