Patient Registration Form - CHILD
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Give us a big smile and snap a shot!
Contact Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Parent or Guardian
FULL NAME
Contact Number
Do you have Private Health Fund
*
Yes
No
Health Fund
Membership and Serie
Medicare
Number
Serie
Medical History
Do you have any medication allergies?
*
Yes
No
If yes, tell us more ...
If your CHILD is an existing Casuarina Dental patient and have previously completed this form, please indicate if there have been any medical changes in the past two years, such as new medications, operations, or allergies.
No
Yes
This is my first-time visiting Casuarina Dental
GP Doctor
Contact N.
Your current medication (including herbal, dietary supplements, naturopathic medicine)
*
Yes
No
If yes, tell us more ...
Does your child have any present illness? if yes, select from the options below.
*
Asthma
Cancer
Cardiac disease
Psychiatric Condition
Epilepsy
Stomach or Digestive Problems
Bleeding Disorder
ADHD
Heart murmur/Heart Disease
Hepatitis (A/B/C)
Stroke Blood Pressure High/Low
Thyroid Disorder
Diabetes T1 or T2
Artificial Heart/ Valves
Vale Defect
Rheumatic Fever
Taking Bisphosphonates
Bone Disease
HIV
Congenital Heart Defect
Angina
Regular ENT infections
None
Other
Tell us more ...
Dental History
If your CHILD is an existing Casuarina Dental patient and have previously completed this form, please indicate if there have been any dental changes in the past two years. This includes wisdom teeth removal or eruption, pain, or sensitivity.
No
Yes
This is my first-time visiting Casuarina Dental.
Is this your child's first dental visit?
Yes
No
When did your child have his/her last dental visit?
-
Day
-
Month
Year
Date
Are your child experiencing any pain, or are you concerned about his/her oral health?
How often do your child brush his/her teeth?
1x day
2x day
3x day
Tell us more ...
How often does your child floss his/her teeth?
1x day
2x day
3x day
I don't floss
Please, select from the options below.
*
Sleep Apnea
Excessive snoring
Day tiredness
Stop breathing
Lack of energy
Choking or gasping during sleep
Poor Concentration
Frequent visits to the bathroom during the night
Falling asleep during the day
Bed wetting
Gum disease
Croked Teeth
Mouth Breathing
Incorrect Jaw Development
Speech problem
None
Other
The purpose of dental materials or restorative materials is to replace the tooth structure that has been lost. Restorative materials vary according to their intended use, and their characteristics vary as well:
*
I am happy to let the dentist decide which material is best for each restorative situation, based on knowledge of the material properties, biocompatibility, aesthetics, and application.
I wish to further discuss with my dentist the material to be used.
Would you like to discuss anything with the dentist regarding your child oral health or smile appearance?
For your child comfort: There are still many people who are nervous about going to the dentist. Even though techniques and anesthetics have improved, your child may still be apprehensive and would like us to take extra measures to ensure your comfort. Please tell us the number that indicates your child present level of apprehension:
Easy
1
2
3
4
5
6
7
8
9
Petrified
10
1 is Easy, 10 is Petrified
Privacy Policy
Would you like to receive email communications from us, such as appointment and recall reminders, as well as our newsletter?
*
Yes
No
Do you consent to the use of photos/videos for medical studies, social media, or advertising?
*
Yes
No
Where did you hear about us?
*
Facebook
Instagram
Flyer at your mailbox
I searched on Google
Google advertising
YouTube
Passing by the front door
The Commons advertising
Magazine
TV
Radio
Word-of-Mouth
If you choose Word-of-Mouth. Kindly let us know who referred you to us so that we can thank them.
No accounts are kept in this office; hence is practice policy that payments are to be made on the day of the treatment.
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