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Home » New Patient Form Child

New Patient Form Child

Name*
First Name Last Name
Parent or Guardian's Name*
First Name Last Name
Birth Date*
Date Format: MM slash DD slash YYYY
Parent's Home Phone
Parent's Work Phone
Email*
Select a Choice*
- Male
- Female
Is there anyone else in your household that is a patient here?*
- Yes
- No
Can you give us their name please?*
Person to Contact in Case of Emergency*
Relationship to Patient*
Phone Number*
How Did You Hear About Us?*
Please tell us the name of the family or friend who referred you.
How would you prefer your appointment reminders?*
- Via Mail
- Phone Call
- Text Message
Do you have insurance that covers this child?*
- YES
- NO
Do you have secondary insurance?*
- YES
- NO
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
INS Information
List Medications
Patient Medical History
Physician*
Physician's Office Phone
Is the child currently under any medical treatment?*
- YES
- NO
Has the child been admitted to a hospital or needed emergency care during the past two years?*
- YES
- NO
Is the child currently taking any medications, including over the counter medications?*
- YES
- NO
Has the child ever had any complications following dental treatment?*
- YES
- NO
Do you have or have had any of the following? Please check all that apply.*
- AIDS/HIV
- Anemia
- Arthritis
- Artificial Joints
- Asthma
- Blood Disease
- Cancer
- Diabetes
- Dizzieness
- Epilepsy
- Excessive Bleeding
- Fainting
- Glaucoma
- Head Injuries
- Heart Disease
- Heart Murmur
- Hepatitis
- High Blood Pressure
- Kidney Disease
- Liver Disease
- Mental Disorders
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Rheumatic Fever
- Rheumatism
- Sinus Problems
- Stomach Problems
- Strock
- Tuberculosis
- Tumors
- Venereal Disease
- Smoker
- None
Do you have any allergies to medications?*
- YES
- NO
Patient Dental History
Check All That Apply*
- Gums bleed while you brush
- Your teeth are sensitive to hot or cold liquid/foods
- You feel pain in any of your teeth
- Have any sores/lumps in your mouth
- Have any head, neck or jaw injuries
- Ever experience any clicking or pain in the TMJ area, difficulty opening or closing
- Have frequent headaches
- You clench or grind your teeth
- You bite your lips or cheeks frequently
- Had any difficult extractions or prolonged bleeding from it in the past
- Had any orthodontic treatments
- You wear dentures or partials
- None
Upload a Photo
We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.
I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Carstairs Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.
*
- I have read the above conditions of treatment and payment and agree to their content.

Pay Bright - Dental Insurance

Our Office

Address

1118 Hammond St. Carstairs,
Alberta T0M 0N0 Canada

Phone

(403) 337-2332

Email

info@carstairsdental.com

Business Hours

Monday: 10am – 6pm
Tuesday: 10am – 6pm
Wednesday: 8am – 4pm
Thursday: 8am – 4pm
Friday: 8am – 4pm
Saturday: Closed
Sunday: Closed

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CONTACT

Carstairs Dental
Dr. Herman Nijjar
1118 Hammond St, Carstairs, AB T0M 0N0, Canada
(403) 337-2332
info@carstairsdental.com

OFFICE HOURS

Monday: 10am to 6pm
Tuesday: 10am to 6pm
Wednesday: 8am to 4pm
Thursday: 8am to 4pm
Friday: 8am to 4pm

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