Children’s Patient Form Please complete and submit before your child’s first appointment. Patients Name First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City PhoneBirthDate MM slash DD slash YYYY Parent Name First Last Business Phone: For preferred Trillium Dental Location, please select from dropdown list below:Select locationMinto DowntownAlta VistaBayshoreKanataStittsville WestJackson TrailsOrleansWestgateHow did you hear about our office? Please check any of the following that apply: Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Is another member of your family, or a relative a patient at our office? Their name: Is this your child's first visit to the dentist? Date of your child's last visit to the dentist: Date of your child's last dental xrays: Date of your child's last dental cleaning: Does your child have any sensitive teeth to hot/cold/sweets to bite on? Does he or she suck on their thumb? Has your child ever had any of the following?Checkbox Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Does your child have or have they ever had any of the following?Please check any of the following that apply: Artificial Heart Valve Heart Murmur Heart Surgery Heart Pacemaker High Blood Pressure Rheumatic Fever Epilepsy or Seizures Fainting or Dizzy Spells Bruise Easily Diabetes: Diet or Medication controlled Hepatitis A Hepatitis B It has been suggested that your child neds pre-medication prior to dental treatment. None of the above For ParentsDo you brush your child teeth? Does your water contain fluoride? Has your child been under medical care during the past two years? Is your child now taking medication? If yes, please list: Has your child had an adverse reaction to any medications? If yes, please explain: Dental InsuranceDo you have dental insurance? Primary Policy Holder Insurance Company Secondary Policy Holder Parent Name ( required for under 18 years ) First Last Parent Signature ( required for under 15 years of age )*Use your mouse or finger to draw your signature aboveCAPTCHA
