New Patient Dental/Health Form

Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.

Please correct the errors described below.

1. Tell Us About Your Child

2. Who is Accompanying the Child Today?

3. Parent's Information

Add new row

Add new row

4. Neighbor or Relative Not Living With You

5. Primary Dental Insurance

6. Dual (Secondary) Insurance

7. Health History

8. Dental History

I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

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.