Child Health History Form

To learn more about what makes our team and practice so unique, or to schedule your first appointment, get in touch with Pittsford Family Dental and a member of our staff will be happy to get you started.

We can be reached by phone at 585-248-5250 or via email through our contact page.

Mother's Information

Father's Information

Medical History

Does your child have, or has he/she ever had the following?

Dental History

Current Oral Health Habits

Does your child receive fluoride in any of the following forms?