PLEASE COMPLETE ENTIRE FORM
Please check yes or no if your child has been diagnosed or treated for any of the following:
Please provide details if you answered yes to anything above (i.e: type, etc).
Please list anything else not listed above and elaborate.
If yes, please explain.
If yes, please explain.
Dental History
If yes, please explain.
Is There Anything You Can Tell Us To Help “Connect” With Your Child?
Does your child currently do any of the following? (Please checkall that apply):
Breast FeedBottle FeedGrindThumb/Finger SuckUse a PacifierNONE
What Type of Water Is Present In Your Home?
Filtered Water (from tap or fridge)Reverse OsmosisWell WaterBottled Water
Any Other FormsOf Fluoride? (Rinse,Vitamins, etc.)
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