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 4300 S Park Dr #270, Stony Plain, AB T7Z 2W7
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Child's New Patient Form
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- Personal Information
16%
Name
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First Name
Last Name
Date of Birth
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Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Emergency Contact
*
Emergency Contact Number
*
What's your child's main concern right now?
*
When was your child's last dental visit?
*
Previous Dental Office
*
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
How did you hear about us?
*
Google Search
Google Ads
Flyers
Billboard
Social Media (Facebook & Instagram)
Social Media Ads
Word of Mouth
Family Member of Current Patient
Patient of Associated Offices
Newspaper, Radio, TV
Do you have dental insurance for your child?
*
Yes
No
Name of Insurance Subscriber
*
First Name
Last Name
Date of Birth for Policy Holder
*
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Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Do you have a secondary dental insurance for your child?
*
Yes
No
Name of second Insurance Subscriber
*
First Name
Last Name
Date of Birth for Policy Holder
*
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2014
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2012
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Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Has the child had any problem with dental treatment in the past?
*
Yes
No
Has the child had orthodontic treatment in the past?
*
Yes
No
Has the child ever had X-Rays?
*
Yes
No
Has the child ever suffered any injuries to the mouth, head or teeth?
*
Yes
No
Please explain.
*
Does your child have any serious Medical Conditions we should know about?
*
Yes
No
Please explain.
Known Medical Conditions
Alcohol/ Drug Abuse
Angina
Arthritis
Asthma
Blood Disorder
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Dizziness/Fainting
Emphysema
Epilepsy/Seizures
Frequent Headaches
Gag Reflex
Hay Fever
Head Injuries
Hearing Disabled
Heart Attack
Heart Murmur
Hemophilia
No Known Medical Issues
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
Hepatitis A/B/C
High Blood Pressure
HIV/AIDS
Joint Replacement (hip, knee, etc)
Kidney Disease
Liver Disease
Low Blood Pressure
Lung Disease/ Tuberculosis
Mental Disorder
Mitral Valve Prolapse
Multiple Sclerosis
Pacemaker
Radiation Therapy
Respiratory Problems
Sinus Problem
STD
Stomach/Intestinal Problems
Stroke
Thyroid Disorder
Ulcer
Other
If Other selected, please specify:
*
Does your child have any allergies to medication or substances?
*
Yes
No
What Allergies do you have?
Is your child taking any prescription medication or herbal remedies?
*
Yes
No
Please list off your child's medications
*
Has your child been treated for any other illness not listed above?
*
Yes
No
If Yes selected, please specify:
*
Does your child need to be medicated with antibiotics prior to dental treatment
*
Yes
No
How many times a day are the children's teeth brushed?
*
When are your children's teeth brushed?
Does the child suck their thumb, a pacifier or their fingers?
*
Yes
No
At what age did the child stop bottle feeding?
*
At what age did the child stop breast feeding?
*
Is fluoride toothpaste used?
*
Yes
No
Does the child take fluoride supplements?
*
Yes
No
What type of water does your child drink?
*
City Water
Well Water
Bottled Water
Filtered Water
Has your child ever been hospitalized?
*
Yes
No
If Yes selected, please specify:
*
Does the child have any speech difficulties?
*
Yes
No
If Yes selected, please specify:
*
Has the child ever had a blood transfusion?
*
Yes
No
Is the child physically, mentally, or emotionally impaired?
*
Yes
No
Does the child experience excessive bleeding when they are cut?
*
Yes
No
Is this the child's first dental visit?
*
Yes
No
If No is selected, when was the child's last dental visit?
*
Does the child participate in active recreational activities?
*
Yes
No
Has your child recently been under the care of a physician?
*
Yes
No
Name of Physician
*
Physician's Phone Number
*
When was your child's last visit with the physician?
*
Current Health Condition
*
Excellent
Good
Fair
Poor
Is there anything else we should know about your child?
Full Name of Legal Guardian/Parent responsible for the form
*
First Name
Last Name
Consent
*
I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize North Stony Dental to preform any necessary dental services that I may need.
Signature
*
Dentistry Made Simple.
Thanks For Filling In Our Form.
About Us
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Contact Us
Our Office
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Dr. Dorota Szula
Blog
Services
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Expand
Orthodontics
Expand child menu
Expand
Invisalign
Myobrace
Braces
Children’s Dentistry
Dental Hygiene
Schedule Your Appointment
Phone
(780) 968-4414
