Test Signature Please enable JavaScript in your browser to complete this form.Your Child's Name *FirstLastYour Child's Date of Birth *Parent or guardian's name: *FirstLastRelationship *Parent or gaurdian's contact phone number: *Has your child had a cough or fever in the past 2 weeks? *YesNoHave you had a cough or fever in the past 2 weeks? *YesNoHas your child been exposed to anyone in the past 2 weeks with fever and/or cough? *YesNoAny dental problems? *YesNoPlease list dental problems: *Any specific dental concerns? *YesNoPlease describe dental concerns: *Any medical changes since last visit? *YesNoPlease explain medical changes: *Any recent hospitalizations? *YesNoPlease describe the reasons for hospitalization: *Any medications? *YesNoPlease list the medications: *Change of address? *YesNoAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance change? *YesNoPlease indicate your insurance, group number, subscriber’s DOB and ID: *Please upload a copy of the insurance card * Click or drag a file to this area to upload. Please upload a copy of your ID: * Click or drag a file to this area to upload. Signature *Clear SignatureNameSubmit