Patient Information

Patient Name:
Date
[date date-9307* date-format:mm/dd/yy]
Gender
Weight
AHC#
D.O.B
Phone (Home):
(Cell):
Best time to call
Address:
Email:
City:
Province:
Postal Code:
Responsible Party Information

Mother’s Name:
Occupation:
Employer:
Birth Date:
YesNo
MarriedSingleOther
Phone Work: Ext: E-mail:
Father’s Name:
Occupation:
Employer:
Birth Date:
YesNo
MarriedSingleOther
Phone Work: Ext: E-mail:
Address:
Health Information

Date of Last Dental Visit:
Reason for this visit:
Has your child ever had any of the following? Please check those that apply:

YesNo
ADHD
YesNo
Allergies
YesNo
Anemia
YesNo
Anxiety
YesNo
Artificial Joints
YesNo
Asperger’s
YesNo
Autism
YesNo
Asthma
YesNo
Blood Disease
YesNo
Cancer
YesNo
Dizziness
YesNo
Epilepsy
YesNo
Excessive Bleeding
YesNo
Fainting
YesNo
Hay Fever
YesNo
Head Injuries
YesNo
Heart Disease
YesNo
Heart Murmur
YesNo
Hepatitis
YesNo
Jaundice
YesNo
Liver Disease
YesNo
Mental Disorders
YesNo
Nervous Disorders
YesNo
Pacemaker
YesNo
Radiation Treatment
YesNo
Respiratory Problems
YesNo
Rheumatic Fever
YesNo
Rheumatism
YesNo
Sinus Problems
YesNo
Stomach Problems

YesNo
Tumors
YesNo
Ulcers
YesNo
Codeine Allergy
YesNo
Penicillin Allergy
YesNo
Tuberculosis
YesNo
Kidney Disease
YesNo
Diabetes
YesNo
Other
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If my child ever has any changes to their health, I will inform the doctors at the next appointment without fail.

Has your child ever had any complications following dental treatment?
YesNo
YesNo
If yes, please explain:
Has your child ever been admitted to a hospital or needed emergency care during the past two years?
YesNo
YesNo
If yes, please explain:
Is your child under the care of a physician?
YesNo
YesNo
If yes, please explain:
Name of Physician: Phone
· Does your child have any health problems that need further clarification?
YesNo
YesNo
If yes, please explain:
Is your child taking any medications?
YesNo
YesNo
If yes, please explain:
Referral Information

Whom may we thank for referring you to our practice?
YesNo

Another patient, friendAnother patient,relative

Dental OfficeYellow PagesNewspaperSchoolWorkOther
Name of person or office referring you to our practice:
Insurance Information

Primary
Name of Insured Insurance company:
Insured's Birth Date
ID #:
Group #:
Insured's Address:
Patient's relationship to insured?
YesNo
SelfSpouseOther

Secondary

Name of Insured Insurance company:
Insured's Birth Date
ID #:
Group #:
Insured's Address:
Patient's relationship to insured?
YesNo
SelfSpouseOther
Consent for Services

Signature of Parent/Guardian
Date:
Relationship to Patient