Child Medical Form

Child Medical Form

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  • PARENTS/GUARDIANS INFORMATION
  • PARENT 1 INFORMATION
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  • PARENT 2 INFORMATION
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  • INSURANCE INFORMATION
  • PRIMARY INSURANCE
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  • SECONDARY INSURANCE
  • I authorize release to my insuring company the information contained in claims submitted electronically on my behalf.
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  • DENTAL HISTORY
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  • MEDICAL HISTORY
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  • I certify that I have read and understood the above questions. If I had questions about this form, they were answered to my satisfaction. I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions I may have made in completing the form. I am also aware that if my child has missed or short notice canceled two or more appointments, it is this clinic's policy that arrangements will need to be made for my child to been seen at a different dental clinic that better accommodates my schedule.
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