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Child Health Dental History Form

Child Health/Dental History Form

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Patient's Name
Have you (the parent/guardian) or the patient had any of the following diseases or problems?
  • Active Tuberculosis
  • Persistent cough greater than a three-week duration
  • Cough that produces blood?

If you answer yes to any of the three items above, please stop and return this form to the receptionist.

Has the child had any history of, or conditions related to, any of the following:
Please list the name and phone number of the child’s physician:

Child's History

If Yes

If Yes

If Yes

If Yes

If Yes

If No

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment

I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Date

5/18/2024

For Office Use Only:

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  • Monday09:00 AM - 05:00 PM
  • TuesdayClosed
  • Wednesday09:00 AM - 05:00 PM
  • Thursday09:00 AM - 05:00 PM
  • FridayClosed
  • Saturday08:45 AM - 02:00 PM
  • SundayClosed
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