Children's Form

DATE

Date

Your cooperation in filling out the data on the confidential questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain with this office.

Last

First

Middle

Prefers to be called (if different)

Age

MaleFemale

Date of Birth

Date

Home Phone

Format: (000) 000-0000.

Street

City

Province

Postal Code

Favourite Sport/Hobby

Family Physician

Phone Number

Format: (000) 000-0000.

Previous Dentist

City / Address

Whom may we thank for referring you

Name

Relationship

Address

Telephone

Format: (000) 000-0000.

Name

Home Phone

Format: (000) 000-0000.

Business Phone

Format: (000) 000-0000.

Street

City

Province

Postal Code

YesNo

Name of Insurance Company

Insurance Policy Number

SIN or Certificate Number

Driver's Licence Number

1. When did your child last visit the physician?

Reason

YesNo

If so, describe

YesNo

If so, describe

YesNo

5. If yes to any of the above, please describe

YesNo

If yes, describe

YesNo

Penicillin

Other Antibiotics

Other Drugs

Local Anaesthesia

General Anaesthesia

YesNo

If yes, describe

YesNo

If yes, when was last visit

YesNo

If yes, please describe

YesNo

If yes, describe

YesNo

If yes, describe

YesNo

7. How often does your child brush?

Floss?

YesNo

13. If there is any specific problem regarding your child's teeth and oral health which concerns you, or if there is any additional information which you feel may be helpful in our care of your child? Please state:

I, the undersigned, acknowledge that I have provided an accurate personal and medical-dental history and to the best of my knowledge, al the preceding answers are true and correct. I wil inform you if there are any changes ni this person's health or medications at future appointments.

You may contact their physician, fi necessary, to discuss any relevant medical information.

I consent to the performing of any dental procedures and x-rays agreed to be necessary or advisable and I will ascsuhmanegeanayn responsibility for fees associated with such procedures. I understand that 48 hours notice must be given fi I need to appointment, otherwise a fee may be charged.

Signature

DATE

Date

DOCTOR

PATIENT INFORMATION

Child's full name

Address

In case of emergency notify

Person Responsible for Account

Address

CONFIDENTIAL MEDICAL HISTORY

4. Has you child ever had any of the following?

10. Is your now taking, or has he or she had:

CONFIDENTIAL DENTAL HISTORY

4. Is there family history of

5. Does your child have any oral habits such as

CONSENT FOR TREATMENT AND OFFICE POLICY