Child's Dental/Medical History Form

Please correct the errors described below.

PLEASE FILL OUT COMPLETELY(THIS IS PROTECTED MEDICAL INFORMATION)

Required Parent/Guardian Information (patient is a minor):

Insurance:

Medical/Dental:

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.

PERMISSION TO RELEASE HEALTH INFORMATION

(THIS PERMISSION INCLUDES INFORMATION REGARDING MY DENTAL HEALTH CONDITION, FINANCES, APPOINTMENT SCHEDULING, ANY OTHER INFORMATION).

I understand that this authorization is valid and in effect until such time as I withdraw it in writing or in person.

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.

Your information will be encrypted.

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