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Medical History

Doatienes your child have any of the following medical conditions?

Any other health conditions not listed above?

Yes No

Has your child ever been hospitalized for any illness or surgery?

Is your child allergic to any of the following?

Any other allergies not listed above? *

What type of toothpaste does your child use?

Has your child been examined or treated by another dentist?

May we contact your child's previous dentist to obtain records?

Were x-rays taken of the teeth or jaws?

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 patient's health. It is my responsibility to inform Smile Squad Kids Dental of any changes in medical status.

Clear

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