Medical Intake form

Patient Name*

FirstMiddleLast

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Please indicate if you or your child has had any of the following:

If Yes, please explain & note if the issue has since been resolved:

Are you or your child allergic or sensitive to any foods or medications?

YesNo

If Yes, please indicate & note reaction

Do you or your child take any medication regularly or taking any medication currently?

YesNo

Medication/Dose

How does your child receive fluoride?

NoneDrops/TabsRinseToothpaste

To the best of my knowledge the above questions have been accurately answered.

Patient / Parent Signature*

Date*

Date

Relationship

Health History Update