• Welcome to our practice! We strive to make each of your child's visits pleasant and comfortable. Our goal is to teach your child oral habits which will help keep their smile beautiful for their lifetime.

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  • Your Child

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  • Mother

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  • Father

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  • Who is responsible for making appointments?

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  • Regardless of divorce judgements we consider the responsible party for the payment of any co-pay or balance due to be the parent or guardian that brings the child to appointments.

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  • Health History: Your Child's overall health as well as any medications which your child takes could have an important interrelationship with dental care your child receives. Please answer each of the following questions completely.

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  • Health History

  • Authorization and Release

    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 my child's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child during the period of such dental care to third party payors and/or health practitioners. I authorize benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

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  • Should be Empty: