Has the patient ever had any of the following medical problems?
Does/Has the patient have/had any of the following habits?
The Parent or Guardian who accompanies the child is responsible
for payment. Our office is committed to meeting or exceeding the
standards of infection control mandated by OSHA, the CDC and the
Please check your form to make sure it is complete and press the
submit button when you are done. You will see a confirmation page
when your form has been successfully submitted. Thank you!