Child New Patient Form

General Information

Parent Information

Insurance Information

Primary Insurance

Health History Questionnaire

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Dental History

Please indicate if your child has any of the following mouth habits:

Allergies to medications

Are you allergic to any of the following

Has your child had a history of any of the following?

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any services rendered. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my child's health status or the information provided.