Registration Form

Patient Information

Date of Birth

Parent/Guardian Information

Dental Information

Medical Information

Does your child have or had a history of:

AsthmaBleeding DisorderHeart ConditionKidney DiseaseAutism/Autism Spectrum DisorderAttention Deficit DisorderDiabetesAnemiaAllergyLiver DiseaseEpilepsyHearing DifficultyImpaired VisionMental Disability

Does your child have any other special healthcare needs? Please mention:

Hospitalisations/Allergies if any, please specify: