Registration Date

Registration No.

Patient Information

Date of Birth

Parent/Guardian Information

Dental Information

Medical Information

Does your child have or had a history of:
Asthma

Bleeding Disorder

Heart Condition

Kidney Disease

Autism/Autism Spectrum Disorder

Attention Deficit Disorder

Diabetes
Anemia

Allergy

Liver Disease

Epilepsy

Hearing Difficulty

Impaired Vision

Mental Disability
None

 

Does your child have any other special healthcare needs? Please mention:
Hospitalisations/Allergies if any, please specify:

Subscribe to our newsletter

WANT THE BEST ORAL HEALTH FOR YOUR CHILD?

Subscribe to Dentician newsletters to receive insights on a cavity free mouth.

Subscribe to our mailing list