CHILD HISTORY FORM

Confidential Patient Information

Confidential Responsible Party/Parent/Legal Guardian Information

Dental Insurance Information

Emergency Information

DENTAL HISTORY

UPDATES - OFFICE USE ONLY

I have verbally reviewed the medical/dental information above with the patient named herein.

MEDICAL HISTORY

I affirm 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 understand that, where appropriate, credit bureau reports may be obtained.