Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential.

  • Health History Update Form

  • Signature

    I understand 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 in my child’s medical status. I authorize the dental staff to perform the necessary dental services my child may need.
  • (Please use your mouse or finger on a touchscreen to sign in the box.)
  • Date Format: MM slash DD slash YYYY