Richmond West End / Glen Allen 804-270-7737

Family and cosmetic dentistry

We provide individualized treatment geared
toward improving your dental & overall health.

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Child Dental Registration and History

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    Required fields are in *Bold

    Patient Information



    MaleFemale









    YesNo


    Dental Insurance








    YesNo












    YesNo





    Dental History





    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    Medical History





    YesNo


    YesNo


    YesNo


    YesNo



    Has Minor/Child had any history of or difficulty with any of the following? If yes, please check.

    aidsAIDS/HIV

    anemiaAnemia

    asthmaAsthma

    bladderproblemsBladder Problems

    cancerCancer

    cerebralpalsyCerebral Palsy

    convulsionsConvulsions

    diabetesDiabetes

    drugabuseDrug Abuse

    epilepsyEpilepsy

    faintingFainting

    hearingproblemsHearing Problems

    heartproblemsHeart Problems

    hepatitisHepatitis

    kidneydiseaseKidney Disease

    liverdiseaseLiver Disease

    measlesMeasles

    mononucleosisMononucleosis

    mumpsMumps

    rheumaticfeverRheumatic Fever

    sinusproblemsSinus Problems

    thyroiddiseaseThyroid Disease


    In case of an emergency, whom should we call?



    Generate signature (Responsible party)Leave blank and print


    Next up is the financial agreement form and last is the acknowledgement of privacy practices form. Fill out those 2 forms to finish preregistration.

    Richmond West End / Glen Allen 11551 Nuckols Road - Suite B Glen Allen, VA 23059

    Open Monday to Thursday 8AM TO 5PM

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