New Patient Child

PERSONAL INFORMATION
Name*

First NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth *

DayMonthYear
Date
Gender
Referred By? (ie: Google, Walk By, Friend or Family Member Name)
How did you hear about us?*

Google SearchGoogle ReviewLive in AreaFamily/Friend ReferralDentist/Specialist ReferralOther
Please provide the name of the person or office who referred you.*
Emergency contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Please enter a valid phone number.
INSURANCE INFORMATION
Dental Insurance Information (if applicable): Insurance Carrier Name
Dental Insurance Information: Subscriber Name & Birthdate
Dental Insurance Information: Relation to Subscriber
Dental Insurance Information: Policy / Plan/ Group #
Dental Insurance Information: Certificate or ID #
Alberta Health Care #*
Payment Options
Patients are responsible for payment of all dental services. All dental services are charged directly to the patient when treatment is rendered. For your convenience, we accept Debit, Visa & MasterCard. For patients with dental insurance coverage, we will assist submitting claim forms for your direct reimbursement. Note: it is the responsibility of the patient/insurance subscriber to understand the benefits & limitations of their dental coverage plan. Please initial indicating you have read the above.*
Personal Information Disclosure Agreement
We are committed to protecting the privacy of our patients’ personal information & to utilizing all personal information in a responsible and professional manner. Patient personal information is collected and used for the purpose of updating personal profiles, invoicing, processing insurance claims, sending reminders and sending information to patients about out dental practice. Patient medical information is collected and used for the purpose of diagnosing dental conditions, treatment planning and providing dental treatment. Please initial indicating you have read the above.*
Cancellation Policy
Glamorgan Dental requires 2 business days notice to cancel or reschedule a reserved appointment. A $75 fee will apply to changes to reserved appointments with insufficient notice. Please initial indicating you have read the above.*
Mission Statement: Your Smile + Our Work = Together It’s Our Commitment for Better Oral Health! Our goal is to treat our patients based on their needs and wants for optimal dental and overall health. Each team member plays an important part in our success. Our satisfaction comes from patients who appreciate our efforts, care about their health and well-being and take responsibility for wanting the best level of care for themselves, their family and their friends.
INFORMED CONSENT
I, the undersigned, do hereby authorize and consent to the administration of all dental procedures deemed necessary or advisable for myself, or my child, by the attending dentist, including but not limited to, the use of local anesthetics or other prescribed medications. I shall assume the responsibility for payment of all fees associated with treatment procedures provided. I consent to collection, use and disclosure of my personal information for the purposes outlined in the personal information consent agreement. I have reviewed the foregoing information and consent. I have had the opportunity to ask questions and understand the above consent.
Patient Signature*

Clear
Date*

DayMonthYear
Date
DENTAL HISTORY
How would you rate the condition of your mouth?*

GoodFairPoor
Name of current or previous dentist.
Date of most recent dental treatment.
Date of most recent dental exam.*
Date of most recent xrays.*
Date of most recent dental cleaning.
I routinely see my dentist every:

3 months4 months6 months12 monthsNot routinely
What is your immediate dental concern?*
Please select if any of the below apply.

Are you fearful of dental treatment?Have you had an unfavorable dental experience?Have you ever had complications from past dental treatment?Have you every had trouble getting numb or reactions to local anesthetic?Do you often feel tired, fatigued, have a hard time concentrating?Do you snore?Do you have sleep apnea?Have you ever had a sleep test or study?Is there anything about the appearance of your teeth that you would like to change?Have you ever whitened (bleached) your teeth?Are you self-conscious about yoru teeth?Have you been disappointed with the appearance of previous dental work?Do you have problems chewing gum?Do you have problems chewing bagels or other hard foods?Have your teeth changed in the last 5years, become shorter, thinner or worn?Are your teeth crowding, developing spaces or catching food?Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?Did you ever have braces or had your bite adjusted?Do you have any problems with sleep or wake up with an awareness of your teeth?Have you ever had any teeth removed?Do you have dentures or partial dentures?Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping?Do you have tension headaches or sore teeth?Do you wear or have you ever worn a bite appliance?Have you had any cavities withing the past 3 years?Do you have a dry mouth?Do you regularly breathe through your mouth?Are any teeth sensitive to hot, cold, biting or sweets?Have you ever had a tooth ache, cracked filling, broken, chipped or cracked tooth?Do you avoid brushing any part of your mouth?Do you fell or notice any holes(ie: pitting) in your teeth?Do you bite your nails or chew on objects with your front teeth?
Is your sugar intake?

LowModerateHigh
Where does your sugar come from?
Please select if any of the below apply.

Have you every been diagnosed or treated for periodontal (gum) disease?Have you ever experienced gum recession?Is there anyone with a history of periodontal disease in your family?Do your gums bleed when brushing, flossing or eating?Have you ever noticed an unpleasant taste or odor in your mouth?Have you experienced a burning sensation in yoru mouth>
How often do you brush your teeth?
How often do you brush your tongue?
How often do you floss?
Do you use any of the following?

Electronic toothbrushFloss aidsMouth rinseSpecialty toothpaste
MEDICAL HISTORY
Name

First NameLast Name
Family Physician

First NameLast Name
Clinic Name of Physician
Date of recent medical physical examination
How would you rate your general health?*

GoodFairPoor
Please select if any of the below apply.

Hospitalization of illness or injury.Allergy to latexAllergy to aspirin, ibuprofen, acetaminophenAllergy to penicillinAllergy to erythromycinAllergy to tetracyclineAllergy to codeineAllergy to local anestheticAllergy to fluorideAllergy to metals (ie: gold, stainless steel)Other
Please select if any of the below apply.

Heart problems/conditinsHeart murmurRheumatic fever or scarlet feverHigh blood pressureLow blood pressureHistory of strokeArtificial joints or heart valvesPacemakerAnemia or blood disorderProlonged bleeding after cutShortness of breathAsthmaEmphysemaTuberculosisBreathing or sleeping problemsKidney diseaseLiver diseaseThyroid or parathyroid diseaseHormonal deficiencyHigh cholesterolDiabetesStomach problems (ie: ulcer)Digestive disorders (ie: gastric reflud)ArthritisGlaucomaHead or neck injuriesDizziness or faintingEpilepsy/ convulsions or seizuresNeurological problems (ie: memory loss)Viral infections & cold soresAny lumps or swelling in the mouthHives, skin rash or hay feverVenereal dieseaseHepatitis or JaundiceHIV/AIDSTumor or abnormal growthRadiation TherapyChemotherapyAnxiety/DepressionPsychiatric treatmentMad cow disease, Gerstmann-Straussler-Scheinker disease or fatal familia insomniaAre you aware of changes in your general health?Are you on medication for osteporosis/ osteopenia?Are you subject to frequent headaches?Are you often exhausted or fatigued?Are you a smoker or smoked previously?Are you experiencing any lack of muscle coordination, dementia, twitches or tremors?Females-Are you taking any contraceptives?Females-Are you pregnant?MEN- Prostate disorders?Are you being treated for any other illness?Other
Describe any current medical treatment, surgeries or other treatment that you are currently undergoing or will be undergoing:
Please list ALL medications, supplements and/or vitamins taken within the last 2 years.
Signature*

Clear
Date*

DayMonthYear
Date
Sleep & Airway Assesment

Please select if you child exhibits the following:
Have any problems going to bed?
Have trouble falling asleep?
Seem tired upon waking most mornings?
Seem sleepy during the day?
Wake frequently at night?
Move a lot during sleep? (ie: restless)
Have a regular bedtime most days?
Snore or breath loudly while sleeping?
Interrupted breathing or snoring where breathing stops.
Did your child have a tongue tie at birth?

YesNo
If yes, was your child's tongue tie snipped?

YesNo
Is/was your child breast fed?

YesNo
If yes, how long was your child breast fed?
Was your child bottle fed?

YesNo
If yes, how long was your child bottle fed?
Did/does your child use a pacifier(soother, binkie)?

YesNo
If yes, for how long did your child use a pacifier?
Did/does your child suck a thumb or finger?

YesNo
If yes, for how long did your child suck a thumb or finger?
Has your child ever been tested for sleep apnea?

YesNo
If yes, what were the results of the test?
Has your child been seen by an ENT?

YesNo
If yes, what was the reason your child saw an ENT?
Has your child seen an allergist?

YesNo
If yes, what was the reason for your child's visit to an allergist?
Did/does your child have persistent difficulty nose breathing?

YesNo
Does your child have asthma?

YesNo
Has your child seen an orthodontist?

YesNo
If your child has the seen an orthodontist, what is the doctors name?
If yes, have they had any active treatment?

ExpanderRetianerBracesInvisalignOther
Please indicate any unresolved or un addressed issues after orthodontic therapy.

Bite issuesNarrow jawsHeadachesDisorder of the jaw (TMD)Grinding or clenchingRecessionRelapse crowdingAirway & breathing issues (ie: snoring, poor nose breathing)
Please check all that may apply NOW or in the Past.

Mouth breathing at nightMouth breathing during the dayFrequent stuffy noseThroat and/or tonsil infectionsEar infectionsHeadachesAllergic symptomsLower % of weight or heightTalks in sleepSleep walking or night terrorsCurrent bed wettingHistory of bed wettingNight time sweatingTeeth grindingHard to wake in the morningExcessively daytime sleepinessSpeech problemsHoarseness or nasal speeechSensory issuesSchool struggles (ie: reading, math)Difficulty focusing/short attentionADD/ADHD and/or anxietyPicky eaterSwallowing problems
Should be Empty:

PERSONAL INFORMATION

INSURANCE INFORMATION

Payment Options

Personal Information Disclosure Agreement

Cancellation Policy

INFORMED CONSENT

DENTAL HISTORY

MEDICAL HISTORY

Sleep & Airway Assesment