WWW.KIDSHAPPYTEETH.COM
SPECIALIZING IN PEDIATRIC DENTISTRY FOR INFANTS,
CHILDREN, TEENS, SPECIAL NEEDS PATIENTS, AND
ORTHODONTICS TOO 
MEDICAL/ DENTAL HISTORY/CONTACT UPDATE (Required Every 6 Months)
CHILDS NAME_________________________________________ DOB__________________
ADDRESS (Parent/Guardian)______________________________________________
CITY___________________________STATE__________ ZIP CODE______________
HOME #________________ CP#_________________WORK#____________________
EMAIL_______________________________________________
DO YOU HAVE ANY CONCERNS/QUESTIONS ABOUT YOUR CHILDS DENTAL
HEALTH THAT WE CAN ANSWER TODAY ?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
**Any Allergies? ________________________________________________________
In order to keep your child’s record up to date and accurate, Please CIRCLE any changes
since the last six months and note below to explain/clarify :
Home address
Phone number
Parents marital status
Financial responsibility
Dental insurance
Parents name
medical condition
heart murmur
current medicines
hospitalization
allergies
behavior problems
oral habits
speech therapy
stained teeth
broken teeth
crooked teeth
mouth sores/ulcers
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SIGNATURE PARENT/GUARDIAN_________________________________________
RELATIONSHIP TO CHILD___________________________________________
TODAYS DATE___________________________________
FOR THE SAFETY OF OUR PATIENTS AND YOUR CHILD, WE REQUIRE MEDICAL HISTORY
UPDATES
THANK YOU FOR YOUR TIME
Roswell Pediatric Dentistry and Orthodontics
Canton Pediatric Dentistry and Orthodontics
Perimeter Pediatric Dentistry and Orthodontics
10930 Crabapple Rd., Ste 106. Roswell, Ga 30075
3395 Sixes Rd. Ste 140. Canton, Ga 30114
2221 Johnson Ferry Rd. Ste 2-A. Atlanta, Ga 30319
Email:[email protected]
Tel 678 352 1090
Tel 770 720 0079
Tel 770 407 6549
Fax 678 352 1029
Fax 770 720 0045
Fax 678 352 1022