| CHILD’S NAME: |
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AGE: |
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| 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” |
|
|
| 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 |
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| NEW Insurance Company /Group#,if any |
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| Signature: |
|
Date: |
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| Name of child’s physician: |
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Phone: |
|
| |