Test Signature - The Dentist for Kids

Your Child's Name *

First

Last

Your Child's Date of Birth *

Parent or guardian's name: *

First

Last

Relationship *

Parent or gaurdian's contact phone number: *

Has your child had a cough or fever in the past 2 weeks? *

Have you had a cough or fever in the past 2 weeks? *

Has your child been exposed to anyone in the past 2 weeks with fever and/or cough? *

Any dental problems? *

Please list dental problems: *

Any specific dental concerns? *

Please describe dental concerns: *

Any medical changes since last visit? *

Please explain medical changes: *

Any recent hospitalizations? *

Please describe the reasons for hospitalization: *

Any medications? *

Please list the medications: *

Change of address? *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance change? *

Please 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 *