Growing Smiles Pediatric Dentistry and Orthodontics Continuing Care Update
Child's Name
Age
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have there been any changes in your child's health since the last examination?
Yes
No
Is your child taking any medications?
Yes
No
Have there been any recent injuries to the teeth, head, or neck?
Yes
No
Are there any conditions or problems you wish to bring to our attention?
Yes
No
What is the problem?
Please list changes in health, medications, and/or injuries:
Any insurance or employment changes?
Is there a change in your address or phone number?
Signature
Relationship
Comments
Preview PDF
Submit
Should be Empty: