Our Locations:

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Mesa (480) 610-2300
Phx West (602) 472-3553
Phx East (602) 253-6600
KDC (480) 782-5437
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Kids Dental Center

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Dental Insurance Information

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Patient History

Reason for today’s visit?
Is he/she doing well in school?
Does the child floss teeth daily?
Does he/she get along w/others?
Is the child taking fluoridated supplements?
Does the child brush teeth daily?
Has the child ever had any pain/tenderness in the jaw joint?
Tick any of the following which applies to your child

Medical History

Are test and Immunizations (DPT, diptheria, tetanus, whooping cough, measles and polio, vaccines) up to date?
Has he/she had a skin test for tuberculosis?
Does your child have any history of the following MEDICAL PROBLEMS?
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Magic Smiles Dental