Demographic and Medical History

Updated Demographics & Health History

All required fields must be filled. Use N/A if not applicable
Child's Name:*

First NameMiddle NameLast Name
Date of Birth* Age* Gender*
Parent 1 (present at appointment)*

First NameLast Name
Has your dental insurance information changed? If so, please email updated information to info@sparklesdentistry.com*
Please list any medical conditions: (Asthma, Allergies, Heart disease/disorders, Hepatitis, Neuromuscular disorders, Autoimmune Disorders, Autism Spectrum Disorders, ADD/ADHD, Hematological Disorders, others)*
Please list all current medications: (Over the counter, prescription, vitamins, supplements):*
Please list all allergies: (Medication allergies, food allergies, other)*
Is your child up to date on vaccinations against childhood diseases? (DTap, MMR, HIB, Hepatitis B, Varicella, Pneumococcal, Meningococcal, Hepatitis A)*

YesNoDelayed scheduleOther
If other, please list reason:*
Are there any vaccinations that your child does NOT receive?*

Updated Demographics & Health History