Miles for Smiles – OCHC Dental Clinic

Patient Information Form

Parents of children: The information requested is very important. In order for your child to receive dental care provided by Miles for Smiles, you will need to complete this form for your child. This information form becomes part of our permanent record and will be heald in strict confidence. Please choose Yes or No where indicated. If you are unable to complete this form by yourself, please ask for assistance. If you have questions, call Miles for Smiles at 417-328-6730. Thank you!

Step 1 of 7

Logo
MM slash DD slash YYYY