Primary Insurance Company

Who can we thank for referring you to our office?

Medical History

Parents/Guardians please respond and check Yes or No

Please check if your child has a history of the following conditions

Dental History

Dental Experience

Oral Habits

Has your child ever had any of the following habits?

(please indicate ages when the habit occurred)

Oral Hygiene and Diet

History of Dental Injuries

Fun Facts


To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in medical status.

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