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949-306-6938
Class Location:
Primrose School of Royal Palm Beach
Palm Beach County
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Client Intake Forms
Home Page
Parents Name
Child's Name
Email Address
Preschool
Last Name
Child's Date of Birth
Phone
Is your child in a bed or crib?
*
Bed
Crib
Is your child taking any medication (murilax, fiber, etc.)
*
No
Yes
If you answered yes, please elaborate
Has your pediatrician cleared your child for potty training?
*
No
Yes
Does your child have any special needs?
*
No
Yes
If you answered yes, please elaborate
Is your child in any type of OT, PT, or Early Intervention program for a developmental delay?
*
No
Yes
If you answered yes, please elaborate
Does your child have any special needs?
*
No
Yes
If you answered yes please elaborate
Does your child have constipation issues?
*
No
Yes
If you answered yes are you doing anything to help?
I declare that the info I’ve provided is accurate & complete
Medical Release
I agree to the terms & conditions of the Medical Release
Non Disclosure
I agree to the terms & conditions of the Non Disclosure
Your Signature
Clear
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