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Child Medical/Dental History Form

  • Child Medical/Dental History Form

  • Date Format: MM slash DD slash YYYY

  • DENTAL HISTORY

  • Date Format: MM slash DD slash YYYY

  • MEDICAL HISTORY

    Has the child experienced the following medical problems?

  • Does/did the child experience any of the following?

  • Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

    I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.

  • Date Format: MM slash DD slash YYYY

  • OFFICE USE ONLY

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

  • Medical History Update (In office only)

  • This field is for validation purposes and should be left unchanged.