Child Patient Information



Child HISTORY PATIENT INFORMATION/CLINICAL HISTORY


Parent's Information


Parent's Information

If responsible party is other than the patient's parent, please give information:








Please list any other significant information regarding your medical history

DENTAL HISTORY:

Do you have any of the following habits?

GROWTH AND DEVELOPMENT:

Any further information you can provide concerning your child is greatly appreciated. The more we know about each patient, the more helpful we can be in managing the orthodontic treatment, both at home and in the office. Also, please include special interests and hobbies:

I understand that the above medical and dental information is correct. If there are any changes to my clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.










I, the undersigned, do hereby consent and agree that John A. Pavlo,DMD,PC and its employees have the right to take photographs, video-tape, or digital recordings of me for the use of all media purposes, including teaching, website and facebook. I also consent that my name and identity may be revealed by descriptive text or commentary.