Patient Registration Form – Children

PATIENT INFORMATION

Last Name

First Name

Date of Birth

Address

City

Postal Code

Parent / Guardian Name

Home Phone

Cell Phone

In case of emergency please contact:

Emergency Contact Number

INSURANCE INFORMATION OF PARENT/GUARDIAN

Primary Insured

Date of Birth (YYYY-MM-DD)

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

If the child has secondary coverage:

Secondary Insured

Date of Birth (YYYY-MM-DD)

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

MEDICAL HISTORY

Name of Physician

Address of Physician

City

Postal Code

Office Phone Number

Are you currently under medical treatment?

Yes No

Reason (if yes)

Have you had an allergic or unusual reaction to any of the following? (Please check mark the boxes below)

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetic

Yes No

Penicillin

Yes No

Other

Have you ever been treated for any of the following? (Please check mark the boxes below)

Anemia

Yes No

Asthma

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Hay Fever

Yes No

Heart Murmurs

Yes No

Hepatitis

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Rheumatic Fever

Yes No

Sinus Trouble

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Other

Please answer all questions below:

Does he/she take any medications? If so, what are they?

Yes No

Reasons

Does he/she have any heart problems? If so, what kind?

Yes No

Reasons

Does he/she have any congenital or developmental disorders/disabilities?

Yes No

Reasons

Has he/she ever had any major operations? If so, what kind?

Yes No

Reasons

Has he/she ever been involved in a serious accident?

Yes No

Reasons

Has he/she recently had a communicable disease (i.e. Mumps, Measles, etc.)?

Yes No

Reasons

Please answer all questions below:

Previous Dentist

Date of Last Visit

In past years have they been to a dentist on a regular basis? How often?

Is he/she presently in any dental pain?

Is any part of his/her mouth sensitive to temperature, pressure or sweets?

Does he/she have an unpleasant taste or odor in their mouth?

Does he/she awaken with pain in their teeth or jaws?

Does he/she engage in any oral habits (i.e. thumb-sucking, tongue thrusting)?

Please list some typical snacks he/she consumes on a regular basis.

Does he/she consume juice on a regular basis?

What is your major dental concern for your child at this time?

PLEASE READ THE FOLLOWING CAREFULLY

Office Policy

Payment is required after EACH appointment for work done that day.
We will gladly complete Dental Insurance Claim Forms with the following understanding:
a) The parent/guardian is financially responsible for the entire cost of the treatment.
b) Payment is to be made to “Dental Land Professional Corporation” by the patient/guardian or by direct billing to the insurance company.

iTrans

Benefits payable from claims submitted electronically will be assigned to Dental Land and payment will be received by the Dentist directly.

CANCELLATION/ NO SHOW POLICY

At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
Missed Appointments will incur a firm charge of $50.00
All outstanding fees must be paid in full before further appointments will be booked.
Should you miss an appointment, it is your responsibility to call and rebook.
Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.

Statement of Understanding
I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Dental Land Professional Corporation's policy and understand that breaching it in anyway may result in disciplinary action.

Name of Patient

Name of Parent/Guardian

Date Signed

Message

PARENT/ GUARDIAN ACCEPTANCE

THIS IS TO CERTIFY THAT I, THE UNDERSIGNED, CONSENT TO DENTAL AND ORAL SURGERY PROCEDURES WITH THE USE OF LOCAL ANAESTHETIC AND/OR RELATIVE ANALGESIA AS AGREED TO BE NECESSARY OR ADVISED BY THE DENTAL PROFESSIONAL, AND WILL ASSUME RESPONSIBILITY FOR FEES ASSOCIATED WITH THOSE PROCEDURES.

By checking this checkbox, I hereby understand and agree to the conditions mentioned above.

Patient Registration Form – Children

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