• Child Health History Form

  • About Your Child

  •  -
  • Parents or Guardians


  •  -
  •  -
  • Medical Health Information

  •  -
  • Dental Insurance Information

  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • Dental Health Information

  • How often does your child brush and floss?

  •  -
  • Personal Information

  • Photo Release

  • I acknowledge that the above information is correct. I will notify Dr. Jewett of any changes that occur after this date. I hereby authorize Dr. Jewett and his team to perform an initial orthodontic evaluation/examination.

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty: