New Patient Child - Airdrie Springs Dental

Name

First NameLast Name

Parent or Guardian's Name

First NameLast Name

Birth Date

Date

Parent's Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Parent's Work Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Select a Choice

Is there anyone else in your household that is a patient here?

Can you give us their name please?

Person to Contact in Case of Emergency

Relationship to Patient

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How Did You Hear About Us?

Type Here

Please tell us the name of the family or friend who referred you.

How would you prefer your appointment reminders?

Do you have insurance that covers this child?

Do you have secondary insurance?

Physician

Physician's Office Phone

Please enter a valid phone number.Format: (000) 000-0000.

Is the child currently under any medical treatment?

Has the child been admitted to a hospital or needed emergency care during the past two years?

Is the child currently taking any medications, including over the counter medications?

Has the child ever had any complications following dental treatment?

Do you have or have had any of the following? Please check all that apply.

Do you have any allergies to medications?

Check All That Apply

We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.

I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Airdrie Springs Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.

Patient Medical History

Patient Dental History

Upload a Photo