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CHILD MEDICAL HISTORY FORMS
BRIARCLIFF SMILE DESIGN

It is important that you schedule your appointment first and then fill up the medical history forms part 1 and part 2 both.

CHILD MEDICAL HISTORY FORM

PART -1

Please fill out the following form below regarding your child medical history so that we provide the best care!
 

About your child

Thanks for submitting!

ACKNOWLEDGEMENT

I understand that the information that I have given is correct to the best of my knowledge, that I will be held in the strictest of my confidence and it is my responsibility to inform Briarcliff Smile Design dental office of any changes in my child's medical status.

I authorize the dentists team to perform the necessary dental services my child may need.

CHILD MEDICAL HISTORY FORM

PART-2

If you or your child have any questions, please feel free to call or email us at any time.

About You

Does your child brush his/her teeth daily?
Rate your child' oral health?
Please rate your child's medical health?
Has your child ever had any of the following mediacal conditions o problems?(please select all of the conditions if any)

Thanks for submitting!

NOTE: The Parent or Guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved. Click to learn more about our

Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA. Please read about HIPAA COMPLIANCE HERE.

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