We look forward to seeing you:

Jeffery C. Summers, DMD

CHILD FORM

Please take this time to tell us about your child
First
Middle
Last
Nickname

WHO’S ACCOMPANYING THE CHILD TODAY?

MOTHER’S INFO :

FATHER’S INFO :

INSURANCE

Primary Dental Insurance



PERSON RESPONSIBLE FOR ACCOUNT

GENERAL DENTIST

MEDICAL HISTORY

A complete history is vital for a proper orthodontic evaluation.
GIRLS:
Has he/she ever had any of the following diseases or medical problems? (Please circle all that apply.)

MEDICAL ALERT INFORMATION


Is he / she allergic to any of the following?

DENTAL HISTORY

What are your main concerns that you would like orthodontics to correct?
Does/did your child have any of the follow habits? (Please circle)
I hereby certify that I have reviewed the above medical and dental history and agree that it is, to the best of my knowledge, accurate at this time. I am also aware that communication with dentist/specialist may be necessary for treatment. If there are any future changes in this information I will inform the practice of these changes.