Patient Registration

  • Barry P Setzer, DDS
  • Stephen D Cochran, DMD
  • Flavio M Soares, DDS

Patient Medical and Dental History

Child's Name:

Child's Nickname:


Pediatrician's Phone Number:


Date of Birth:


Who may we thank for referring you?:

Medical History

Dental History

Patient Registration

Responsible Party Information

May we request of your child's medical records for our references?  

May we forward information regarding your child's dental records to your primary care physician and/or Dentist?  

Leave this empty:

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Signature Certificate
Document name: Patient Registration
lock iconUnique Document ID: 973f331f396cb7a46a67b3beee7f2f5484807a11
Timestamp Audit
January 26, 2022 7:17 pm CDTPatient Registration Uploaded by Setzer Cochran - IP