Zoo Crew Dentist

6 Month Dental/Medical Update (Hermitage)

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Is your child taking any medication? *
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Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.

Medical Conditions * 
 

If you have additional children under the same address and insurance provider, check below.  If you have additional children with different information you will need to fill out a new form.
Additional Child (2):
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Is your child taking any medication? *
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health? *

Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.

Medical Conditions * 
 

Additional Child (3):
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Is your child taking any medication? *
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health? *

Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.

Medical Conditions * 
 
Additional Child (4):
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Is your child taking any medication? *
0/255 characters
Have there been any changes in the past 6 months in your child's medical or dental health? *
Medical Conditions * 
 

Check any of the following that may pertain to your child. If none, choose My child does not have any medical conditions.

If you have more than 4 children, please fill out another 6 month update once this form has been submitted.

I authorize and request my insurance company to pay directly to the dentist or dental group those insurance benefits otherwise payable to me. I agree to be responsible for payment of all services rendered on behalf of my dependents. I understand that I am to call 48 hours in advance to confirm my child’s dental appointment. Failure to call and confirm will result in cancellation of his/her appointment.

Parent/Guardian *
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