DENTAL ANESTHESIA SERVICES OF LOUISIANA
Pediatric Online Registration Form
General Information
Patient's Initials
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Age
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Gender
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Please Select
Male
Female
Appointment Date
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Please select a month
January
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Month
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Day
Please select a year
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Year
Dentist
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Pediatric Dental Partners- Drs Backofen, Chidlow, Crawford, and Wallace
Dr Heber Tuft
Shreveport Bossier Family Dental for Kids- Drs Stewart
Bossier Endodontics- Dr Jay Tuner
Gilmer Endodontics- Dr John Gilmer
Parent/Guardian's Name
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First Name
Last Name
Best Contact Number
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-
Area Code
Phone Number
Medical History
Any past surgeries ? If so any problems with anesthesia?
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Has anyone in the child's family had a reaction to anesthesia?
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Yes
No
What medications, supplements and over the counter items does your child take regularly or are currently prescribed:
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Is your child allergic to any medication? What type of reaction?
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Let's get a current picture of your child's health
Health History
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No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Stroke, seizure, other neurologic problem
High blood pressure, heart failure, chest pain, irregular heart beat
Asthma, TB, sleep apnea, snoring, recent cold or cough
Hepatitis, bleeding problem, liver problems
Hiatal hernia, ulcers, frequent heart burn
Diabetes or low blood sugar
Problem with kidneys
Additional medical information not listed above
I have read the pre and postprocedure instructions and cancelation policy (located on forms page), fully understand them and agree to their terms (please sign with your cursor below).
*
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