Patent Recall Form

TELL US ABOUT YOUR CHILD

Child’s Name

Nickname

Child’s Birthdate

Child’s Age

Child’s Address

Home Phone

Guardian’s Email

Best Phone No.

DENTAL HISTORY

Please explain

Does your child have any of the following habits?

Lip Sucking/Biting

Nursing/Bottle Habits

Nail Biting

Thumb/Finger Sucking

Does your child have any current dental issues?

Toothache/pain

Bleeding Gums

Broken tooth or trauma

Discolored

Cavities

Bad Breath

Grinding

Sensitivity

HEALTH HISTORY

OTHER MEDICAL CONDITIONS

ALLERGIES

MEDICATIONS

DENTAL INSURANCE

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Patent Recall Form

TELL US ABOUT YOUR CHILD

DENTAL HISTORY

HEALTH HISTORY

DENTAL INSURANCE

Anderson Pediatric Dentistry