Rabitz Pediatric Dentistry

Gregory K. Rabitz, DDS

Locations in Willow Glen and Los Gatos

Los Gatos Willow Glen

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PLEASE CHOOSE OFFICE LOCATION

LOS GATOS        WILLOW GLEN 

CHILD’S NAME:		AGE:
Is your child in Good Health?		Yes No
Is your child currently under treament by physician for any reason?		Yes No
Is your child receiving any medications or drugs?		Yes No	If yes, which
To your knowledge, is your child sensitive or allergic to anything, including medications, nuts, or latex?		Yes No	If yes, what
HAS YOUR CHILD HAD ANY HISTORY OF: If Yes, please explain under “Remarks”
AIDS Cerebral Palsy Heart Disease Mononucleosis Anemia Chicken Pox Hemophilia Mumps Asthma Convulsions Hepatitis in Family Psychiatric Treatment Birth Disease Diabetes HIV-Positive Rheumatic Fever Bladder Disease Drug Problems Kidney Disease Scarlet Fever Blood Disease Epilepsy Liver Disease Sinus Infection Blood Transfusion Fainting Malignancies Thyroid Bronchitis Hearing Problems Measles Tuberculosis
Other(please explain):
Has your child had any unfavorable experience with previous medical or dental care?		Yes No
Remarks:
FOR INSURANCE PURPOSES:
Mother’s Name:		Birthdate:
Father’s Name:		Birthdate:
NEW Address/Phone
NEW Insurance Company /Group#,if any
Signature:		Date:
Name of child’s physician:		Phone:
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Los Gatos Pediatric Dentistry
15827 Los Gatos Blvd Ste B,
Los Gatos, CA 95032
(408) 356-4900

Dr. Rabitz Pediatric Dentistry
1600 Willow St Ste 250,
San Jose, CA 95125
(408) 265-5880