• In order to render optimum health care service, it is necessary to become acquainted with the vital information related to each patient. Of course, all information is strictly confidential. Although some questions may seem unimportant at the moment, they may be vital in case of emergency. Therefore PLEASE ANSWER EVERY QUESTION. Please feel free to ask the receptionist for help in completing this form.
  • Date**
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  • Birth Date**
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  • Do we need to send the insurance claims on your behalf?**
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  • Is child now under the care of a physician?**
  • Has child ever had any serious illness or been treated in the hospital?**
  • Is child now taking any medicine?**
  • Is child allergic to any medicine or food?**
  • Has child ever had any unfavourable reaction to any previous medical or dental care?**
  • Has child ever had any of the following conditions? (please ✓ any that apply)**
  • 9 Out of 10 children suffer with these symptoms (please ✓ any that apply)**
  • Has child had previous dental care?**
  • Has child ever had an accident, injury or surgery about the mouth?**
  • Has child ever had an unpleasant experience associated with a dental visit?**
  • Is the child particularly nervous about visiting the dentist?**
  • Have child’s teeth ever been treated with decay-preventing Fluoride?**
  • Has child ever had Orthodontic treatment?**
  • Does child have any oral habits such as:**
  • Is there a family history of:**
  • I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications perform such diagnostic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the medical and dental histories are correct to the best of my knowledge. I understand that my dental insurance (if insured) is a contract between the insurance carrier and me and not between the insurance carrier and the dentist and that I am still responsible for all the dental fees. I understand that I will be charged for all dental treatment and that any payments received by the Dental Office from my insurance company will be credited to my account or refunded to me if I have paid the dental fees incurred.
  • I hereby consent to the performing of the Dental and Oral Surgery procedures necessary or advisable for my children, including the use of Local Anesthesia and/or Relative Analgesia, as indicated, and I accept responsibility for the fee.
  • Date**
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  • Should be Empty: