New Patient Form Additional Child

Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply.


Name*

Birth Date*

Select a Choice*
MaleFemale
Address/ City /Prov /Postal code*
Parent or Guardian's Name*
Parent's Home Phone*
Parent's Work Phone
Email*
Is there anyone else in your household that is a patient here?*
NoYes
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 MailPhone CallText Message
Do you have insurance that covers this child?*
NoYes
Do you have secondary insurance?*
NoYes

Patient Medical History

Physician*
Physician's Office Phone
Is the child currently under any medical treatment?*
NoYes
Has the child been admitted to a hospital or needed emergency care during the past two years?*
NoYes
Is the child currently taking any medications, including over the counter medications?*
NoYes
Has the child ever had any complications following dental treatment?*
NoYes
Do you have or have had any of the following? Please check all that apply.*
AIDS/HIVAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzienessEpilepsyExcessive BleedingFaintingGlaucomaHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureKidney DiseaseLiver DiseaseMental DisordersPacemakerRadiation TherapyRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrockTuberculosisTumorsVenereal DiseaseSmokerNone
Are they pregnant?*
NoYes
Do they have any allergies to medications?*
NoYes

Patient Dental History

Check All That Apply*
Gums bleed while you brushYour teeth are sensitive to hot or cold liquid/foodsYou feel pain in any of your teethHave any sores/lumps in your mouthHave any head, neck or jaw injuriesEver experience any clicking or pain in the TMJ area, difficulty opening or closingHave frequent headachesYou clench or grind your teethYou bite your lips or cheeks frequentlyHad any difficult extractions or prolonged bleeding from it in the pastHad any orthodontic treatmentsYou wear dentures or partialsNone
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 Beacon Smiles 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.