Name
*
First Name
Last Name
Parent or Guardian's Name
*
First Name
Last Name
Birth Date
*
Date Format: MM slash DD slash YYYY
Parent's Home Phone
Parent's Work Phone
Email
*
Select a Choice
*
Male
Female
Is there anyone else in your household that is a patient here?
*
Yes
No
Can you give us their name please?
*
Person to Contact in Case of Emergency
*
Relationship to Patient
*
Phone Number
*
How Did You Hear About Us?
*
Please Select
Family/Friend
Website
Publication
Yellow Pages
Radio
E-Brandon
Other
Please tell us the name of the family or friend who referred you.
How would you prefer your appointment reminders?
*
Via Mail
Phone Call
Text Message
Do you have insurance that covers this child?
*
YES
NO
Do you have secondary insurance?
*
YES
NO
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
INS Information
List Medications
Patient Medical History
Physician
*
Physician's Office Phone
Is the child currently under any medical treatment?
*
YES
NO
Has the child been admitted to a hospital or needed emergency care during the past two years?
*
YES
NO
Is the child currently taking any medications, including over the counter medications?
*
YES
NO
Has the child ever had any complications following dental treatment?
*
YES
NO
Do you have or have had any of the following? Please check all that apply.
*
AIDS/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizzieness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Mental Disorders
Pacemaker
Radiation Therapy
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Strock
Tuberculosis
Tumors
Venereal Disease
Smoker
None
Do you have any allergies to medications?
*
YES
NO
Patient Dental History
Check All That Apply
*
Gums bleed while you brush
Your teeth are sensitive to hot or cold liquid/foods
You feel pain in any of your teeth
Have any sores/lumps in your mouth
Have any head, neck or jaw injuries
Ever experience any clicking or pain in the TMJ area, difficulty opening or closing
Have frequent headaches
You clench or grind your teeth
You bite your lips or cheeks frequently
Had any difficult extractions or prolonged bleeding from it in the past
Had any orthodontic treatments
You wear dentures or partials
None
Upload a Photo
We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.
I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Didsbury Smiles Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.
*
I have read the above conditions of treatment and payment and agree to their content.