Child Medical History Form

Kindly fill in the child medical history form below

Fields marked * are required.

Patient Information Form CHILD (≤17 years)

Dental & Medical History

Guardian/ Parental Information For Account Purposes

Parent 1 Details

Parent 2 Details

In signing this form I acknowledge that this represents an accurate medical history. I will also supply my dentist with any relevant changes to this history as required. All medical information will be treated with complete professional confidentiality within the guidelines of the Privacy Act 12/01 and through the obligations health service providers have under the Professional and Ethical Codes of Practice.

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