New Patient Forms

New Patient Forms

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    PARENT’S INFORMATION
    PARENT’S EMAIL ADDRESS


    CHILD’S HISTORY









    To the best of my knowledge the above information is complete and correct, I understand that it is my responsibility to inform my dentist if my minor child ever has a change in health.

    MINOR CHILD CONSENT

    I am the parent, guardian or personal representative of and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental staff to perform necessary and full services for the child named above, including but not limited to x-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present when treatment is rendered.