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