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Health History Update Form

Your Child's Medical Information

1. Is your child currently:
2. Since your child’s last dental visit, has your child:
3. Does your child have, ever had, or been diagnosed since their last dental visit with any of the following: (please check all that apply)
4. Does your child have any other condition not mentioned above?

Your Child's Dental History


I understand the information I have given is correct to the best of my knowledge and will be held in the strictest of confidence. I understand it is my responsibility to inform this office of any changes in my child’s medical status.


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