Skip to content
Menu
About Us
Contact Us
Our Office
Dr. Lorne Wasylucha
Dr. Arash Boroumandi
Blog
Services
Orthodontics
Invisalign
Myobrace
Braces
Sedation Dentistry
Children’s Dentistry
Dental Hygiene
Forms
Forms
X-Ray Release Form
New Patient Forms
Call : (780) 968-4414
Book An Appointment
Menu
About Us
Contact Us
Our Office
Dr. Lorne Wasylucha
Dr. Arash Boroumandi
Blog
Services
Orthodontics
Invisalign
Myobrace
Braces
Sedation Dentistry
Children’s Dentistry
Dental Hygiene
Forms
Forms
X-Ray Release Form
New Patient Forms
Call : (780) 968-4414
Book An Appointment
Child's New Patient Form
Step 1 of 5 - Personal Information
20%
Name
*
First Name
Last Name
Date of Birth
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
*
Do you have dental insurance for your child?
*
Yes
No
Name of Insurance Subscriber
*
First Name
Last Name
Date of Birth for Policy Holder
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
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
*
Does your child need to be medicated with antibiotics prior to dental treatment
*
Yes
No
Has your child been treated for any other illness not listed above?
*
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
*
