NEW PATIENT FORMS

  • Cara L Donley DMD PC Pediatric Dentistry

    Patient Registration and Health History
  • BIRTH DATE*
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  • BIRTH GENDER*
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  • Is this your child's first visit to the Dentist?*
  • Do you have any dental concerns for your child?
  • Does your child have any habits which might affect the mouth or teeth? ( click all that apply)*
  • Has your child ever experienced Trauma to the mouth and teeth?*
  • Does your child use a sippy cup or bottle?*
  • Has your child had dental X-rays taken?*
  • Date taken:*
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  • Mother's Birth date*
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  • Father's Birth date*
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  • Relationship to Patient*
  • Insured Birth date*
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  • MEDICAL HISTORY

  • Is your child in good health?*
  • Date of last physical exam
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  • Were there any difficulties during the pregnancy or child's first year of life?*
  • Is your child currently taking any medications?*
  • Has your child had any ALLERGIC reactions to any of following ( Click all that apply):*
  • Is your child allergic to any FOODS?
  • Has your child ever been hospitalized or had any surgeries ( operations)?*
  • Has your child ever had problems with:*
  • Are your child immunizations current?*
  • Please check all that apply

  • To the best of my knowledge, the questions on this medical and dental form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my resposibility to inform the dental office of any changes in medical status.

  • Date*
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  • Acknowledgment of Receipt of Privacy Practices

    Cara L Donley, DMD PC 327- B Boston Post Road Sudbury, MA 01776
  • I have received or am aware there is a copy of this office's Notice of Privacy Practices on the website and in the office.*
  • Date*
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  • Informed consent for Dental Procedures

  • YOu, the parent, has the right to accept or reject dental treatment recommended for your child by the dentist. Prior to consenting for treatment, you should carefully consider the anticipated benefits and commonly known risks fo the recommended procedure, alternative treatments, or the option of no treatment.

    Do not consent to treatment unless andunitll you diuscss potential benefits, risks and complications with your child's denitst and all your questions are answered. By consenting to the treatment, you are acknowledging your wllinigness to accept known risks and complications, no matter how alight the probability of occurrence.

    It is very important that you provide your child's dentist with accurate information, beofre, during, and after treatment. It is equally impoirtant that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your child's dentist, you may increase the chances of a poor outcome.

    Please read and respond to acknowledgements below and SIGN at the bottom of the form.

  • TREATMENT TO BE PROVIDED. I understand that during my child's course of treatment as a patient the following may be provided: Examinations, Preventive services, dental radiographs ( x-rays) , restorative treatment ( Fillings), and extractions.*
  • DRUGS/MEDICATIONS. I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues: pain, itching, vomiting, and/or anaphylactic shock ( severe reaction)*
  • CHANGES IN TREATMENT PLANS. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination. I give the dentist permission to make any/ all changes and additions as necessary.*
  • BILLING. I give permission to the dental office to bill my dental insurance provider for the treatment provided, if applicable.*
  • Date*
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  • Should be Empty: