Child's Information

Does child go by another name?

Child's Dental History

Does your child have any of the following?
Lip Sucking/Biting
Nail Biting
Nursing/Bottle Habits
Thumb/Finger Sucking
Were X-Rays taken?
by who?
Does family have a general dentist?
General Dentist
Has the child ever had a serious / difficult problem with previous dental work?
Have there been any injuries to the teeth, face, or mouth?
Is the child’s water fluoridated?
Does the child take fluoride supplements?
Has the child ever had any pain or tenderness in their jaw/joint (TMJ/TMD)?
Does the child brush his/her teeth daily?
Does the child floss his/her teeth daily?

Child's Medical History

Is the child currently under the care of a physician?
Please describe the child’s current physical health?
Does the child have any of the following?
Yes No

Authorization for Care

Our Office is committed to meeting or exceeding the standards and mandated put forth by O.S.H.A., C.D.C., H.I.P.A.A., and the A.D.A.

I understand that the information 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 Children’s Dentistry of Longwood and their staff to perform the necessarydental services my child may need.

Authorization for Care

Dr. David Donald, D.D.S.
Our Office is committed to meeting or exceeding the standards and mandated put forth by O.S.H.A., C.D.C., H.I.P.A.A., and the A.D.A.
I understand that the information 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 Children’s Dentistry of Longwood and their staff to perform the necessarydental services my child may need.

Sign above
One file only.
10 MB limit.
Allowed types: gif jpg jpeg png bmp tif tiff svg.