Please complete one form per child. Thank you.
Child's First Name
Patient's Last Name
Patient's Date of Birth
Does your child have or has had any of the following?
NO KNOWN HEALTH ISSUES
Acid Reflux or GERD
Autism Spectrum Disorder
Bleeding Disorder or bleeds/bruises easily
Breastfeeding Problems/Difficulty (if applicable)
Difficulty Swallowing or Eating certain Textured Foods
Hearing/Speech Problems or Delay
Heart Problems or Heart Surgery
Lip Tie Surgery or Tongue Tie Surgery
MTHFR Mutation / Carrier (Please also mark if either parent has the MTHFR Mutation or is a Carrier)
Tonsil or Adenoid Problems or Removal
If your child has or has had any of the above conditions, please explain.
Has your child ever had surgery or been hospitalized?
If yes, please explain:
Please list any allergies (i.e. medications, latex, foods, etc.):
Please list any medications that your child takes:
Please list the reason for your dental visit and any specific concerns that you may have:
Please list the name of your child's previous dentist and approximate date of his/her last visit:
Has your child ever had any type of negative or adverse reaction to dental anesthetics or dental care? Please explain.
Does your child have any habits?
If "Other" Please explain:
Has your child ever been seen by an Orthodontist (braces)?
Orthodontist Name (if Not Applicable pls put N/A)
We would like to respect your wishes. In all of our operatories, we have televisions on the ceilings. Please let us know if you would like your child to watch Kids Netflix during his or her appointment.
Only during procedures such as fillings
If there is any way that we can make you or your child more comfortable during dental care, please let us know how we can help:
Please type your name
Should be Empty: