Pediatric Dental Specialists - Introductory Information

By providing your cell phone number, you consent to being contacted at that number by our practice and our representatives regarding treatment and your account.
Siblings



Whom may we thank for referring your child to our practice?
Whom may we call in case of an emergency?
Pediatrician
Specialist



Health History

Although dental personnel primarily treat the area in and around the mouth, the mouth is a part of your entire body. Health problems that your child may have, or medication that your child may be taking, could have an important affect in the dental treatment your child receives. Thank you for thoroughly answering the following questions.
Medical
Does your child have any known allergies or has child ever reacted adversely to any of the following:
Is your child taking any of the following medications?


Has your child had or does your child currently have any of the following?...
ASTHMATIC PATIENTS ONLY
If yes, please complete the following:




Dental

DISCLOSURE AND CONSENT OF PARENTS
To the best of my knowledge, all of the proceeding answers are true and correct. I understand, if there is any change in my child's health history and/or the medications he/she takes, I will inform the doctor at the next appointment without fail.

Pediatric Dental Specialists
Santos Cortez, D.D.S., Inc. – Ana M. Planells, D.D.S. – Estela Sanchez, D.D.S.
3320 Los Coyotes Diagonal - Suite 200 - Long Beach, CA 90808 – (562) 377-1375 – Fax (562) 377-1343