Intake Form: Child

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Tacoma Office

2302 South Union Ave.
Suite B-14
Tacoma, WA 98405
(253) 752-3949

Monday-Friday
7:30am-4:30pm

Gig Harbor Office

5122 Olympic Dr. N.W.
Suite B-206
Gig Harbor, WA 98335
(253) 851-6789

Monday-Friday
7:30am-4:30pm

Patient
Family Members

Parent 1

Parent 2

Step Parent/Guardian

Siblings:

Dental Insurance

Parent 1

Parent 2

Step Parent/Guardian

Dental History
Medical History

Does Your Child Have Any History Of The Following

Pre-medication needed?

Tonsils and/or Adenoids removed

Under physicians care at this time

To Help Determine Your Childs Growth Potential

Girls

Has she started menstruation (monthly periods)

Boys

Has his voice changed

Has he started to shave

CHECK ANY OF THE FOLLOWING FOR WHICH YOU HAVE BEEN TREATED

Are there any concerns regarding orthodontic treatment?