Health History Update
Thank you for choosing our office for your child's dental care. All information in this form is confidential and transmitted over a secure, encrypted connection.
(*) indicates a required field.
Name, Address and Phone of Child's Physician
I understand 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 authorize the dental staff to perform the necessary dental services my child may need.
Signature of Parent or Legal Guardian *
(Please use your mouse or finger on a touchscreen to sign in the box.)