REGISTRATION FORM
Registration Date
Registration No.
Patient Information
Date of Birth
Parent/Guardian Information
Dental Information
Medical Information
Does your child have or had a history of:
Asthma
Bleeding Disorder
Heart Condition
Kidney Disease
Autism/Autism Spectrum Disorder
Attention Deficit Disorder
Diabetes
Anemia
Allergy
Liver Disease
Epilepsy
Hearing Difficulty
Impaired Vision
Mental Disability
None
Does your child have any other special healthcare needs? Please mention:
Hospitalisations/Allergies if any, please specify: