Children's Dental Center of Madison, S.C.

New Patient Dental/Health Form

Tell Us About Your Child

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Tell Us About Your Child

Gender(Required)
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Child's Home Address(Required)
Do we have a current Financial/Insurance form on file with up-to-date billing and insurance information?

Dental History

Is this your child's first visit to a dentist?(Required)
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Have there been any injuries to the teeth, face, or mouth?(Required)
Does your child have any of the following habits?
Does your child have any current dental issues?
Has your child ever had a serious or difficult problem associated with previous dental work?(Required)
Is your child’s water fluoridated?
Is your child taking fluoride supplements?
Has your child ever had any pain or tenderness in his/her jaw/joint? (TMJ/TMD)?
Does your child brush his/her teeth daily?
Does your child floss his/her teeth daily?

Health History

Has your child ever had any of the following conditions?(Required)
Is your child up to date on immunizations against childhood disease?
Is your child currently under the care of a physician?(Required)
Please describe your child’s current physical health:(Required)

Digital Signature

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