Frederick S. Fritz Child Health History Logo
  • Frederick S. Fritz Child Health History

    We would like to welcome you and your child to our office! In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Please give us a call if you have any questions. Thank you!
  • Patient Information

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  • Parent/Guardian Information

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  • Emergency Contact

    Please provide an emergency contact outside the home, in the event parents cannot be reached.
  • Dental Insurance Information

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  • Health History

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  • Authorization

  • I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical information.


    I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

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