Patient form / sezan-ahmed-core.store

General Information

Patient's First Name *

Patient's Middle Name

Patient's Last Name *

Preferred Name:

Gender *MaleFemaleOther

Patient's Date of Birth *

Age

Phone *

Email Address *

Personal Health Number:

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Physician Information

Name:

Phone

Address

Pharmacy Information

Name

Phone

Address

1st legal Guardian Information

1st Legal Guardian's First Name *

1st Legal Guardian's Middle Name

1st Legal Guardian's Last Name *

Relation to the Patient? *

Please provide more information:

Date of Birth *

Cell Phone *

Other Phone

Email Address *

Is your address different from patient's address? *YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Occupation(optional):

Do you have Insurance? *YesNo

Ins. Company:

Ins. Subscriber’s name:

Policy/Group #

Ins. ID/Certificate:

2nd Legal Guardian Information

2nd Legal Guardian First Name

2nd Legal Guardian Middle Name

2nd Legal Guardian Last Name

Relation to the Patient?

Please provide more information:

Date of Birth

Cell Phone

Other Phone

Email Address

Is your address different from patient's address?YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Occupation(optional):

Do you have Insurance?YesNo

Ins. Name:

Ins. Subscriber’s name:

Policy/Group #

Ins. ID/Certificate:

Medical and Dental History

Note:

Does your child have any allergies to food, antibiotics, sedatives, latex, metals, acrylics, dyes, or nuts any other medications?YesNo

Please Specify:

Does your child visit the physician regularly?YesNo

Date of last visit?

Is your child taking any medication?YesNo

Please specify:

Is your child up to date on immunization against childhood diseases?YesNo

Note:

Has your child been hospitalized?YesNo

When?

Why?

Where?

Do you have any concerns about your child’s teeth?YesNo

Please specify:

Has your child ever been to dentist?YesNo

Dentist's Name:

Last dental visit date:

Has your child had any problems or unpleasant reactions with dental treatment?YesNo

When was the X-Ray taken?

Has your child ever injured their mouth, teeth or head?YesNo

Please Specify:

Does your child participate in any sports or other activities?

Does your child wear a mouthguard during these activities?

Preventive

Are your child’s teeth flossed?YesNo

How often?

Which of the following applies to your child’s diet?

Please let us know about past and current feeding and childhood habits

Breast Feeding

Past

Current

Not Applicable

Age When Stopped

Baby Bottle Use Contents

Past

Current

Not Applicable

Age When Stopped

Sippy Cup Use Contents

Past

Current

Not Applicable

Age When Stopped

Thumb/Finger Sucking

Past

Current

Not Applicable

Age When Stopped

Pacifier

Past

Current

Not Applicable

Age When Stopped

Teeth Grinding/Clenching

Past

Current

Not Applicable

Age When Stopped

Are there any other children in the family?YesNo

How did you hear about us? *

Please Specify:

Additional Information

Please tell me more about your child by answering the following questions. This will help us connect much quicker and better during our dental appointments.

What is your childʼs...

Favourite TV show/cartoon?

What is your childʼs favourite game?

What is your childʼs favourite music?

What is your childʼs favourite food?

What is your childʼs favourite colour?

What is your childʼs favourite activity?

What is your childʼs best friendʼs name?

What is your childʼs hero?

What would be considered the best treat for your child?

Do you have a pet? If yes, what is your petʼs name?

What is your childʼs favourite place?

Anything we should AVOID talking about?

Anything else that you consider important, please add:

Date: *

Signature *