Pediatric Online Registration Form

DENTAL ANESTHESIA SERVICES OF LOUISIANA

Pediatric Online Registration Form
General Information
Patient's Initials*
Age*
Gender*
Appointment Date*

MonthDayYear
Dentist*

Pediatric Dental Partners- Drs Backofen, Chidlow, Crawford, and WallaceDr Heber TuftShreveport Bossier Family Dental for Kids- Drs StewartBossier Endodontics- Dr Jay TunerGilmer Endodontics- Dr John Gilmer
Parent/Guardian's Name*

First NameLast Name
Best Contact Number*

Area CodePhone Number
Medical History
Any past surgeries ? If so any problems with anesthesia?*
Has anyone in the child's family had a reaction to anesthesia?*

YesNo
What medications, supplements and over the counter items does your child take regularly or are currently prescribed:*
Is your child allergic to any medication? What type of reaction?*
Let's get a current picture of your child's health

Health History*

Rows	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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DENTAL ANESTHESIA SERVICES OF LOUISIANA