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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

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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

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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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