Child Health History Form

Please correct the errors described below.

lt is important to have complete answers. All information is, of course, confidential.

What professional referred you to our office?

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.


If Secondary Dental Insurance:

Please upload a photo (FRONT & BACK ) of both Dental & Medical Insurance cards below.

As well as a photo of the FRONT of the policy holder's ID.

    Please upload a file

    Your information will be encrypted.