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Child Patient Information

Confidential Patient Information
Confidential Responsible Party Information
Dental Insurance Information
Emergency Information
CHILD DENTAL HISTORY

Does/did your child have any of the following habits?

Allergic to any of the following?

MEDICAL HISTORY

Has your child had/experienced any of the folling?

I affirm 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. I understand that, where appropriate, credit bureau reports may be obtained.