Child Information

The following information is required by East Village Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Child First Name *

Child Last Name *

Preferred Name

Gender

Address *

City *

Postal Code *

Date of Birth *

Child Health Care Number

Child's Doctor's Name

Doctor's Phone

Parent Information

Info of person responsible for payment of account.

First Name *

Last Name *

Middle

Title

Address (if different)

City

Postal Code

Date of birth

Home Phone *

Cell Phone *

Work Phone

Employer

Email *required for insurance pre-determination

How do you prefer to be contacted?

How did you hear about us? *

Please be very specific. If your option is not listed, please type it in. This information greatly helps us.

Other

Financing Options

Are you interested in Dental Financing or Payment Plan?

Yes

Medical History

Specific History

Has your child been treated for any of the following:*

Does your child have any of the following:

Hepatitis A B C

Dental History

Reason for today's visit? *

Has you child ever been to the dentist?

Date of last visit? (approximate)

Date of last cleaning? (approximate)

Date of last exam? (approximate)

Previous dentist or city of previous dentist?*

Were you happy with your treatment there?*

If no, why were you unhappy? How can we make your child's experience better?

Medications

Name of medication:

Reason for medication:

dosage

Allergies:

Is there anything in your medical or dental history that is not listed and we should know about?

As the parent and/or legal guardian of the patient, I do hereby request and authorize the dentists and staff to examine, clean, and provide dental treatment on my child. I further request and authorize the taking of dental x-rays as may be considered necessary to diagnose and/or treat my child's dental problem. I will allow photographs to be taken of my child or child's teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behaviour by helping them understand the treatment in terms appropriate for their age. The dentists and staff will provide an environment that will help your child learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments. The usual and most frequent risks or complications occurring from dental operative treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding and allergic reactions.

I understand I will be responsible for any charges incurred for my child for dental treatment. I affirm that the information above is correct to the best of my knowledge. I understand it is my responsibility to inform East Village Dental of any changes in my child's medical status.

Parent/Guardian Name *

Date

Child Information

Parent Information

How did you hear about us? *

Financing Options

Medical History

General *

Has your child experienced an unusual reaction to the following:*

Are your child's immunizations current?