Washing Township Dental
Pediatric Medical History
Mary-Kathryn Annuzzi D.M.D.
Annie Creato D.M.D.
474 Hurffville-Crosskeys Road
Atrium One, Suite A - Sewell, NJ 08080

Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus, methicillin resistant staphylococcus aureaus (MRSA), sexually transmitted disease (STD), or human immunodeficiency virus (HIV)/AIDS

Over the couter rinse School fluoride program
Pediatrician applied fluoride Prescription fluoride toothpaste
Prescripiton drops/tablets/vitamins

The information on both pages of this form is accurate and complete to the best of my knowledge. Any errors or omissions in completing this form is solely my responsibility.
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