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(780) 968-4414
info@northstonydental.com
4300 S Park Dr #270, Stony Plain, AB T7Z 2W7

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Child's New Patient Form

Step 1 of 6 - Personal Information

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Name*
First Name Last Name
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address City 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*
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*
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*

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North Stony Dental

We are a family-friendly dental practice, located in the heart of Stony Plain. We serve the communities of Stony Plain, Spruce Grove, Parkland Village and beyond with all their oral health needs.

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(780) 968-4414
info@northstonydental.com
4300 S Park Dr #270, Stony Plain, AB T7Z 2W7

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