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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:

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