Toothbud Medical/Dental History

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Thank you for choosing Toothbud for your child's / children's dental home. This form needs to be completed for each child being seen as a patient at Toothbud. All information in this form is confidential and transmitted over a secure, encrypted connection and will not be sold to any third party.

Tell Us About Your Child

Dental History

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.