Ross Gruber, D.D.S
David Zarabi, D.D.S.

South Shore Pediatric
Dentistry & Orthodontics
285 Sills Rd. #3B
East Patchogue, NY 11772
t: (631) 289-9000
f: (631) 289-9009

Medical History Form - Page 1

Patient

Guarantor

Secondary Contact

Insurance

Pharmacy

Medical History

Dental History

Dental History 2

Authorization

Thank you for choosing us to be your child's dental care provider. Please take a few minutes to fill out this form.

We look forward to working with you and your child!

Child's Full Name

First Name *

Last Name *

Nickname

Child's Date of Birth *

Month *

Day *

Year *

Child's Age

Child's Sex

Male

Female

School Grade

Child Lives With

Mother

Father

Both

Other

Parent's or Guardian's Email

Parents' Marital Status

Single

Married

Separated

Divorced

Widowed

Name(s) and age(s) of other children in family

Name(s) of other children seen in this office

Whom may we thank or referring you to our office?

Is this your child's first visit?

Yes

No

If no, name of former dentist

Who is your family dentist?

11%

About the Dentists

Ross Gruber,
D.D.S.

David Zarabi,
D.D.S.

Conveniently Located

close to Sunrise Hwy
close to the LIE
easy, free parking

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