Name*

Parent or Guardian's Name*

Birth Date*

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 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 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.*

Do you have any allergies to medications?*

YES
NO

Patient Dental History

Check All That Apply*

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.