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Patient Registration

Patient Medical and Dental History

Child's Name:

Child's Nickname:

Pediatrician:

Pediatrician's Phone Number:

Sex:

Date of Birth:

Age:

Who may we thank for referring you?:

May we request of your child's medical records for our references?

May we forward information regarding your child's dental records to your primary care physician and/or Dentist?

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

January 26, 2022 7:17 pm CDT

Patient Registration Uploaded by Setzer Cochran - scheduler2@setzerandcochran.com IP 119.94.50.27