Child History WNY
Please answer the following items as completely as possible. Please complete all sections that apply. Click the 'Submit' button at the bottom of the form when you are finished. Thank you!

Child Health History WNY

Has your child ever had an allergic reaction or
sensitivity reason to the following:

Has your child ever had any of the following conditions?

Please check all that apply​.

Does your child have any habits we should be aware of?

Does your child receive fluoride in:

I understand the above information is necessary to provide
me with dental care in a safe and efficient manner. I have
answered all questions to the best of my knowledge.
Should further information be needed, you have my
permission to ask the respective health care provider or
agency, who may release such information to you. I will
notify the doctor of any changes in my health or medication.

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