New Patient Form for Children


    Emergency Contact Information



    Primary Insurance


    Secondary Insurance:


    Medical History (Please check all that apply):



    Dental History:



    Children and Adolescents:

    Sleep, Breathing & Habit Questionnaire:


    Please indicate if your child experiences or has experienced any of the symptoms below by using this scale to measure the severity of these symptoms.

    0 - No Occurrence
    1 - Occurs Rarely
    2 - Occurs 2 to 4 times per week
    3 - Occurs 5 to 7 times per week