Child Medical History Form - Restoration Orthodontics

Fields marked with an * are required

Patient Information

First Name *

Last Name *

Birthdate *

Gender *

Insurance *

Address *

City *

Postal Code *

Home Phone Number *

Parent's Cell Phone Number

Email

Referred By

Dentist

Reason for seeking treatment *

Is any other family member a patient at our office? *

Yes
No

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