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 Phone*BirthDate* MM slash DD slash YYYY Parent Name* First Last Business Phone:*For preferred Trillium Dental Location, please select from dropdown list below:*Select locationDowntownAlta VistaBayshoreKanataJackson TrailsOrléansWestgateHow 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?* 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?* 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 Please check any of the following that apply: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?* Has your child had an adverse reaction to any medications?* 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 )* Reset signature Signature locked. Reset to sign again Use your mouse or finger to draw your signature aboveCAPTCHA
