Health Questionnaire
Baby's Name *
First and Last Name
Your answer
Baby's Date of Birth *
MM
/
DD
/
YYYY
Baby's Gender *
Name Parent 1 *
First and Last Name
Your answer
Parent 1 Date of Birth *
MM
/
DD
/
YYYY
Parent 1 Relationship to Baby *
Name Parent 2
First and Last Name
Your answer
Parent 2 Date of Birth
MM
/
DD
/
YYYY
Parent 2 Relationship to Baby
Home Address *
Important: Please include COMPLETE mailing address - street address, city and zip code
Your answer
Best Email Address(es) *
Your answer
Best Phone Number *
(XXX) XXX-XXXX
Your answer
May we text this phone number? *
We have found that texting is the easiest and most efficient form of communication.
Would you like medical and dental codes emailed to you? *
While we do not accept insurance, we do our best to provide you with the right information to seek reimbursement from your insurance carrier. Prior to your appointment, we can email you a list of medical and dental codes so that you can research your coverage.
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