1. Do You Have An Appointment?

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  2. Password
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  3. You need to make an appointment to continue. Please click here to request an appointment

  1. How Many Children Would You Like To Add As New Patients

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  3. Child's Information

    First Name
    You must provide a first name.
    Middle Name
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    Last Name
    You must provide a last name.
    Nickname (if any)
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    Sex
    Please choose.
    Date of Birth
    You must provide a Date of Birth
    Age
    You must provide the child's age.
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    Attends what school?
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    Interests hobbies or pets:
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  4. Child's Information

    First Name
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    Middle Name
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    Last Name
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    Nickname (If any)
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    Sex
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    Date of Birth
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    Age
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    Attends what school?
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    Interests hobbies or pets:
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  5. Child's Information

    First Name
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    Middle Name
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    Last Name
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    Nickname (if any)
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    Sex
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    Date of Birth
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    Age
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    Invalid Input
    Attends what school?
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    Interests hobbies or pets:
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  6. Child's Information

    First Name
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    Middle Name
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    Last Name
    You must provide a last name.
    Nickname (if any)
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    Sex
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    Date of Birth
    You must provide a Date of Birth
    Age
    Invalid Input
    Invalid Input
    Attends what school?
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    Interests hobbies or pets:
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  7. Child's Information

    First Name
    You must provide a first name.
    Middle Name
    Invalid Input
    Last Name
    You must provide a last name.
    Nickname (if any)
    Invalid Input
    Sex
    Please choose.
    Date of Birth
    You must provide a Date of Birth
    Age
    Invalid Input
    Invalid Input
    Attends what school?
    Invalid Input
    Interests hobbies or pets:
    Invalid Input

  8. Child's Information

    First Name
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    Middle Name
    Invalid Input
    Last Name
    You must provide a last name.
    Nickname (If any)
    Invalid Input
    Sex
    Please choose.
    Date of Birth
    You must provide a Date of Birth
    Age
    Invalid Input
    Invalid Input
    Attends what school?
    Invalid Input
    Interests hobbies or pets:
    Invalid Input

  9. Child's Information

    First Name
    Invalid Input
    Middle Name
    Invalid Input
    Last Name
    You must provide a last name.
    Nickname (if any)
    Invalid Input
    Sex
    Please choose.
    Date of Birth
    You must provide a Date of Birth
    Age
    Invalid Input
    Invalid Input
    Attends what school?
    Invalid Input
    Interests hobbies or pets:
    Invalid Input

  10. Child's Information

    First Name
    Invalid Input
    Middle Name
    Invalid Input
    Last Name
    You must provide a last name.
    Nickname (if any)
    Invalid Input
    Sex
    Please choose.
    Date of Birth
    You must provide a Date of Birth
    Age
    Invalid Input
    Invalid Input
    Attends what school?
    Invalid Input
    Interests hobbies or pets:
    Invalid Input

    PATIENT HISTORY

    In order to assure your child's safety, comfort and happiness during dental treatment, we need to obtain information from you.
    Please carefully and completely answer the questions below. THANK YOU.

  1. .'s Dental History

  2. Why did you make the appointment?
    Please provide an answer.
  3. Is this your child's first visit to a dentist?
    Please provide an answer.
  4. How long since the last dental visit?
    Invalid Input
  5. Child's previous dentist:
    Invalid Input
  6. Name
    Invalid Input
  7. Address
    Invalid Input
  8. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  9. Please explain:
    Invalid Input
  10. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  11. Please explain:
    Invalid Input

  12. .'s Dental History

  13. Why did you make the appointment?
    Please provide an answer.
  14. Is this your child's first visit to a dentist?
    Please provide an answer.
  15. How long since the last dental visit?
    Invalid Input
  16. Child's previous dentist:
    Invalid Input
  17. Name
    Invalid Input
  18. Address
    Invalid Input
  19. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  20. Please explain:
    Invalid Input
  21. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  22. Please explain:
    Invalid Input

  23. .'s Dental History

  24. Why did you make the appointment?
    Please provide an answer.
  25. Is this your child's first visit to a dentist?
    Please provide an answer.
  26. How long since the last dental visit?
    Invalid Input
  27. Child's previous dentist:
    Invalid Input
  28. Name
    Invalid Input
  29. Address
    Invalid Input
  30. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  31. Please explain:
    Invalid Input
  32. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  33. Please explain:
    Invalid Input

  34. .'s Dental History

  35. Why did you make the appointment?
    Please provide an answer.
  36. Is this your child's first visit to a dentist?
    Please provide an answer.
  37. How long since the last dental visit?
    Invalid Input
  38. Child's previous dentist:
    Invalid Input
  39. Name
    Invalid Input
  40. Address
    Invalid Input
  41. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  42. Please explain:
    Invalid Input
  43. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  44. Please explain:
    Invalid Input

  45. .'s Dental History

  46. Why did you make the appointment?
    Please provide an answer.
  47. Is this your child's first visit to a dentist?
    Please provide an answer.
  48. How long since the last dental visit?
    Invalid Input
  49. Child's previous dentist:
    Invalid Input
  50. Name
    Invalid Input
  51. Address
    Invalid Input
  52. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  53. Please explain:
    Invalid Input
  54. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  55. Please explain:
    Invalid Input

  56. .'s Dental History

  57. Why did you make the appointment?
    Please provide an answer.
  58. Is this your child's first visit to a dentist?
    Please provide an answer.
  59. How long since the last dental visit?
    Invalid Input
  60. Child's previous dentist:
    Invalid Input
  61. Name
    Invalid Input
  62. Address
    Invalid Input
  63. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  64. Please explain:
    Invalid Input
  65. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  66. Please explain:
    Invalid Input

  67. .'s Dental History

  68. Why did you make the appointment?
    Please provide an answer.
  69. Is this your child's first visit to a dentist?
    Please provide an answer.
  70. How long since the last dental visit?
    Invalid Input
  71. Child's previous dentist:
    Invalid Input
  72. Name
    Invalid Input
  73. Address
    Invalid Input
  74. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  75. Please explain:
    Invalid Input
  76. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  77. Please explain:
    Invalid Input

  78. .'s Dental History

  79. Why did you make the appointment?
    Please provide an answer.
  80. Is this your child's first visit to a dentist?
    Please provide an answer.
  81. How long since the last dental visit?
    Invalid Input
  82. Child's previous dentist:
    Invalid Input
  83. Name
    Invalid Input
  84. Address
    Invalid Input
  85. Does your child currently have any dental problems or has your child ever had any major dental problems in the past?
    Please provide an answer.
  86. Please explain:
    Invalid Input
  87. Has your child ever had any unpleasant dental experience?
    Please provide an answer.
  88. Please explain:
    Invalid Input

  1. .'s Medical History

  2. Child's Physician's Name
    Please provide an answer.
  3. Address
    Invalid Input
  4. Phone Number
    Invalid Input
  5. Does your child have regular medical examinations?
    Please provide an answer.
  6. Is your child currently under a physician's care for any reason
    Please provide an answer.
  7. Please explain:
    Invalid Input
  8. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  9. Please explain:
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  10. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  11. Please explain:
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  12. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  13. Please explain:
    Invalid Input
  14. Is your child allergic to any medications, or drugs?
    Invalid Input
  15. Please explain:
    Invalid Input
  16. Is your child currently taking any medications?
    Invalid Input
  17. Please explain:
    Invalid Input
  18. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  19. Please explain:
    Invalid Input
  20. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  21. Please explain:
    Invalid Input

  22. Has . had any history of:

  23. Heart Trouble
    Invalid Input
  24. Heart Murmur
    Invalid Input
  25. Rheumatic Fever
    Invalid Input
  26. Diabetes
    Invalid Input
  27. Kidney or liver disease
    Invalid Input
  28. Epilepsy or nervous system disorder
    Invalid Input
  29. Tuberculosis
    Invalid Input
  30. Asthma or lung problems
    Invalid Input
  31. Bleeding trouble
    Invalid Input
  32. Blood transfusion
    Invalid Input
  33. Hepatitis
    Invalid Input
  34. Please Explain:
    Invalid Input
  35. Other Medical Conditions
    Invalid Input

  36. .'s Medical History

  37. Child's Physician's Name
    Invalid Input
  38. Address
    Invalid Input
  39. Phone Number
    Invalid Input
  40. Does your child have regular medical examinations?
    Please provide an answer.
  41. Is your child currently under a physician's care for any reason
    Please provide an answer.
  42. Please explain:
    Invalid Input
  43. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  44. Please explain:
    Invalid Input
  45. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  46. Please explain:
    Invalid Input
  47. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  48. Please explain:
    Invalid Input
  49. Is your child allergic to any medications, or drugs?
    Invalid Input
  50. Please explain:
    Invalid Input
  51. Is your child currently taking any medications?
    Invalid Input
  52. Please explain:
    Invalid Input
  53. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  54. Please explain:
    Invalid Input
  55. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  56. Please explain:
    Invalid Input

  57. Has . had any history of:

  58. Heart Trouble
    Invalid Input
  59. Heart Murmur
    Invalid Input
  60. Rheumatic Fever
    Invalid Input
  61. Diabetes
    Invalid Input
  62. Kidney or liver disease
    Invalid Input
  63. Epilepsy or nervous system disorder
    Invalid Input
  64. Tuberculosis
    Invalid Input
  65. Asthma or lung problems
    Invalid Input
  66. Bleeding trouble
    Invalid Input
  67. Blood transfusion
    Invalid Input
  68. Hepatitis
    Invalid Input
  69. Please Explain:
    Invalid Input
  70. Other Medical Conditions
    Invalid Input

  71. .'s Medical History

  72. Child's Physician's Name
    Invalid Input
  73. Address
    Invalid Input
  74. Phone Number
    Invalid Input
  75. Does your child have regular medical examinations?
    Please provide an answer.
  76. Is your child currently under a physician's care for any reason
    Please provide an answer.
  77. Please explain:
    Invalid Input
  78. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  79. Please explain:
    Invalid Input
  80. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  81. Please explain:
    Invalid Input
  82. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  83. Please explain:
    Invalid Input
  84. Is your child allergic to any medications, or drugs?
    Invalid Input
  85. Please explain:
    Invalid Input
  86. Is your child currently taking any medications?
    Invalid Input
  87. Please explain:
    Invalid Input
  88. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  89. Please explain:
    Invalid Input
  90. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  91. Please explain:
    Invalid Input

  92. Has . had any history of:

  93. Heart Trouble
    Invalid Input
  94. Heart Murmur
    Invalid Input
  95. Rheumatic Fever
    Invalid Input
  96. Diabetes
    Invalid Input
  97. Kidney or liver disease
    Invalid Input
  98. Epilepsy or nervous system disorder
    Invalid Input
  99. Tuberculosis
    Invalid Input
  100. Asthma or lung problems
    Invalid Input
  101. Bleeding trouble
    Invalid Input
  102. Blood transfusion
    Invalid Input
  103. Hepatitis
    Invalid Input
  104. Please Explain:
    Invalid Input
  105. Other Medical Conditions
    Invalid Input

  106. .'s Medical History

  107. Child's Physician's Name
    Invalid Input
  108. Address
    Invalid Input
  109. Phone Number
    Invalid Input
  110. Does your child have regular medical examinations?
    Please provide an answer.
  111. Is your child currently under a physician's care for any reason
    Please provide an answer.
  112. Please explain:
    Invalid Input
  113. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  114. Please explain:
    Invalid Input
  115. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  116. Please explain:
    Invalid Input
  117. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  118. Please explain:
    Invalid Input
  119. Is your child allergic to any medications, or drugs?
    Invalid Input
  120. Please explain:
    Invalid Input
  121. Is your child currently taking any medications?
    Invalid Input
  122. Please explain:
    Invalid Input
  123. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  124. Please explain:
    Invalid Input
  125. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  126. Please explain:
    Invalid Input

  127. Has . had any history of:

  128. Heart Trouble
    Invalid Input
  129. Heart Murmur
    Invalid Input
  130. Rheumatic Fever
    Invalid Input
  131. Diabetes
    Invalid Input
  132. Kidney or liver disease
    Invalid Input
  133. Epilepsy or nervous system disorder
    Invalid Input
  134. Tuberculosis
    Invalid Input
  135. Asthma or lung problems
    Invalid Input
  136. Bleeding trouble
    Invalid Input
  137. Blood transfusion
    Invalid Input
  138. Hepatitis
    Invalid Input
  139. Please Explain:
    Invalid Input
  140. Other Medical Conditions
    Invalid Input

  141. .'s Medical History

  142. Child's Physician's Name
    Invalid Input
  143. Address
    Invalid Input
  144. Phone Number
    Invalid Input
  145. Does your child have regular medical examinations?
    Please provide an answer.
  146. Is your child currently under a physician's care for any reason
    Please provide an answer.
  147. Please explain:
    Invalid Input
  148. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  149. Please explain:
    Invalid Input
  150. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  151. Please explain:
    Invalid Input
  152. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  153. Please explain:
    Invalid Input
  154. Is your child allergic to any medications, or drugs?
    Invalid Input
  155. Please explain:
    Invalid Input
  156. Is your child currently taking any medications?
    Invalid Input
  157. Please explain:
    Invalid Input
  158. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  159. Please explain:
    Invalid Input
  160. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  161. Please explain:
    Invalid Input

  162. Has . had any history of:

  163. Heart Trouble
    Invalid Input
  164. Heart Murmur
    Invalid Input
  165. Rheumatic Fever
    Invalid Input
  166. Diabetes
    Invalid Input
  167. Kidney or liver disease
    Invalid Input
  168. Epilepsy or nervous system disorder
    Invalid Input
  169. Tuberculosis
    Invalid Input
  170. Asthma or lung problems
    Invalid Input
  171. Bleeding trouble
    Invalid Input
  172. Blood transfusion
    Invalid Input
  173. Hepatitis
    Invalid Input
  174. Please Explain:
    Invalid Input
  175. Other Medical Conditions
    Invalid Input

  176. .'s Medical History

  177. Child's Physician's Name
    Invalid Input
  178. Address
    Invalid Input
  179. Phone Number
    Invalid Input
  180. Does your child have regular medical examinations?
    Please provide an answer.
  181. Is your child currently under a physician's care for any reason
    Please provide an answer.
  182. Please explain:
    Invalid Input
  183. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  184. Please explain:
    Invalid Input
  185. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  186. Please explain:
    Invalid Input
  187. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  188. Please explain:
    Invalid Input
  189. Is your child allergic to any medications, or drugs?
    Invalid Input
  190. Please explain:
    Invalid Input
  191. Is your child currently taking any medications?
    Invalid Input
  192. Please explain:
    Invalid Input
  193. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  194. Please explain:
    Invalid Input
  195. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  196. Please explain:
    Invalid Input

  197. Has . had any history of:

  198. Heart Trouble
    Invalid Input
  199. Heart Murmur
    Invalid Input
  200. Rheumatic Fever
    Invalid Input
  201. Diabetes
    Invalid Input
  202. Kidney or liver disease
    Invalid Input
  203. Epilepsy or nervous system disorder
    Invalid Input
  204. Tuberculosis
    Invalid Input
  205. Asthma or lung problems
    Invalid Input
  206. Bleeding trouble
    Invalid Input
  207. Blood transfusion
    Invalid Input
  208. Hepatitis
    Invalid Input
  209. Please Explain:
    Invalid Input
  210. Other Medical Conditions
    Invalid Input

  211. .'s Medical History

  212. Child's Physician's Name
    Invalid Input
  213. Address
    Invalid Input
  214. Phone Number
    Invalid Input
  215. Does your child have regular medical examinations?
    Please provide an answer.
  216. Is your child currently under a physician's care for any reason
    Please provide an answer.
  217. Please explain:
    Invalid Input
  218. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  219. Please explain:
    Invalid Input
  220. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  221. Please explain:
    Invalid Input
  222. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  223. Please explain:
    Invalid Input
  224. Is your child allergic to any medications, or drugs?
    Invalid Input
  225. Please explain:
    Invalid Input
  226. Is your child currently taking any medications?
    Invalid Input
  227. Please explain:
    Invalid Input
  228. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  229. Please explain:
    Invalid Input
  230. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  231. Please explain:
    Invalid Input

  232. Has . had any history of:

  233. Heart Trouble
    Invalid Input
  234. Heart Murmur
    Invalid Input
  235. Rheumatic Fever
    Invalid Input
  236. Diabetes
    Invalid Input
  237. Kidney or liver disease
    Invalid Input
  238. Epilepsy or nervous system disorder
    Invalid Input
  239. Tuberculosis
    Invalid Input
  240. Asthma or lung problems
    Invalid Input
  241. Bleeding trouble
    Invalid Input
  242. Blood transfusion
    Invalid Input
  243. Hepatitis
    Invalid Input
  244. Please Explain:
    Invalid Input
  245. Other Medical Conditions
    Invalid Input

  246. .'s Medical History

  247. Child's Physician's Name
    Invalid Input
  248. Address
    Invalid Input
  249. Phone Number
    Invalid Input
  250. Does your child have regular medical examinations?
    Please provide an answer.
  251. Is your child currently under a physician's care for any reason
    Please provide an answer.
  252. Please explain:
    Invalid Input
  253. Has your child had any surgery, serious illness, or accident in the past?
    Please provide an answer.
  254. Please explain:
    Invalid Input
  255. Is any future surgery or medical treatment planned at this time?
    Please provide an answer.
  256. Please explain:
    Invalid Input
  257. Does your child have any mental, emotional, or physical handicap?
    Invalid Input
  258. Please explain:
    Invalid Input
  259. Is your child allergic to any medications, or drugs?
    Invalid Input
  260. Please explain:
    Invalid Input
  261. Is your child currently taking any medications?
    Invalid Input
  262. Please explain:
    Invalid Input
  263. Does your child have any allergies/sensitivity's to foods?
    Invalid Input
  264. Please explain:
    Invalid Input
  265. Are you or a healthcare provider concerned with sensory issues?
    Invalid Input
  266. Please explain:
    Invalid Input

  267. Has . had any history of:

  268. Heart Trouble
    Invalid Input
  269. Heart Murmur
    Invalid Input
  270. Rheumatic Fever
    Invalid Input
  271. Diabetes
    Invalid Input
  272. Kidney or liver disease
    Invalid Input
  273. Epilepsy or nervous system disorder
    Invalid Input
  274. Tuberculosis
    Invalid Input
  275. Asthma or lung problems
    Invalid Input
  276. Bleeding trouble
    Invalid Input
  277. Blood transfusion
    Invalid Input
  278. Hepatitis
    Invalid Input
  279. Please Explain:
    Invalid Input
  280. Other Medical Conditions
    Invalid Input

    PARENT/GUARDIAN INFORMATION

    The person who brings the patient to the office is financially responsible.

  1. Parent/Guardian Providing Insurance

  2. Full Name
    Invalid Input
  3. Date of Birth
    Invalid Input
  4. Marital Status




    Invalid Input
  5. Home Address
    Invalid Input
  6. City
    Invalid Input
  7. State
    Invalid Input
  8. Zip Code
    Invalid Input
  9. Home Phone
    Invalid Input
  10. Cell Phone
    Invalid Input
  11. Occupation
    Invalid Input
  12. Social Security
    Invalid Input
  13. Driver's License #
    Invalid Input
  14. Employer
    Invalid Input
  15. Business Address
    Invalid Input
  16. Business Phone
    Invalid Input

  17. Additional Parent/Guardian

  18. Full Name
    Invalid Input
  19. Date of Birth
    Invalid Input
  20. Marital Status




    Invalid Input
  21. Home Address
    Invalid Input
  22. City
    Invalid Input
  23. State
    Invalid Input
  24. Zip Code
    Invalid Input
  25. Home Phone
    Invalid Input
  26. Cell Phone
    Invalid Input
  27. Occupation
    Invalid Input
  28. Social Security #
    Invalid Input
  29. Driver's License #
    Invalid Input
  30. Employer
    Invalid Input
  31. Business Address
    Invalid Input

  1. Insurance

  2. Is your child's dental care covered by a dental insurance program?
    Please provide an answer.

  3. Primary

  4. Subscriber (covered employee)
    Invalid Input
  5. Employer providing insurance
    Invalid Input
  6. Name of Insurance carrier (company)
    Invalid Input
  7. Insurance ID number or badge number
    Invalid Input

  8. Secondary (if applicable)

  9. Subscriber (covered employee)
    Invalid Input
  10. Employer providing insurance
    Invalid Input
  11. Name of Insurance carrier (company)
    Invalid Input
  12. Insurance ID number or badge number
    Invalid Input

  1. Your Full Name
    Invalid Input
  2. Your Email Address
    Please provide a valid email address.
  3. Invalid Input

  4. Acknowledgement of Receipt

    In the course of providing service to you we create, receive and store dental information that identifies you. It is often necessary to use and disclose this dental information in order to treat you, to obtain payment for our services, and to conduct dental care operations involving our office. The Notice of Privacy Practices is available by clicking the link below, and describes these uses and disclosures in detail.

  5. You must agree to these terms to submit this form.
  6. NOTICE OF PRIVACY PRACTICES
  7. I certify that the information provided in this form is correct to the best of my knowledge.
    I also certify that I am the person who I claim to be and I am not falsely representing another individual.

    Use your mouse or trackpad to sign on a computer. Use your finger or stylus pen to sign on a touchscreen device.

  8. You must agree to these terms to submit this form.
  9. Sign Above
    Invalid Input
  10. How did you hear about us?
    Invalid Input
  11. Referring Physician's Name
    Invalid Input
  12. Referring Physician's Address
    Invalid Input
  13. Referring Friend's Name
    Invalid Input