Child Health / Dental History Form

Please correct the errors described below.
  1. Active Tuberculosis
  2. A persistent cough is greater than a three-week duration
  3. Cough that produces blood?

If you answer yes to any of the three items above, please stop and return this form to the receptionist

Please list the name and phone number of the child’s physician:

Child's History

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment

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.