Child Medical and Dental History Form

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Child Medical and Dental History Form

Child Medical and Dental History Form

  • Health Problems and Medication

    Health Problems and medications could have an important interrelationship with a patient's dental care. Please answer all the following:
  • If YES, please explain.
  • If YES, please explain.
  • If YES, please explain.
  • If YES, please explain.
  • If YES, please explain.
  • If the child been seen by the Dental van please indicate when?
  • If the child been to a dentist before, please indicate the name of the dentist and date of exam.
  • The following questions will help us get to know your child so we can help him/her feel comfortable in our office.

  • If YES, please indicate who the child lives with.
  • If YES, please indicate where.
  • If YES, please indicate ages and gender.
  • If YES, please indicate what pets.
  • If YES, please indicate.
  • 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 the patient's health. It is my responsibility to inform the dental office of any change in medical status.

Call The Office

(912) 489-1386
Fax: (912) 764-8533

Office Location

2 Lester Court
Statesboro, GA 30458
Located across from Statesboro High School.