mcbride@rpmdentistry.com
562.421.3747
Form: Pediatric Patient

Form: Pediatric Patient



Tell Us About Your Child






MaleFemale










Who is accompanying the child today?




YesNo





MarriedSingleWidowedDivorcedSeperated

Mother of Child

Father of Child



















Person responsible for account

Billing:






 






Appointments:






 

Primary Dental Insurance

Secondary Dental Insurance










&








What is the primary reason for the child’s appointment?




YesNo


YesNo


YesNo


YesNo


YesNo


YesNo


YesNo





YesNo


GoodFairPoor





Has the child ever had any of the following medical problems?


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo



Has the child ever had any of the following medical problems?


YesNo

YesNo

YesNo

YesNo

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need.



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