SE Calgary Children's Dentistry | Millennium Dental

PERSONAL INFORMATION- CHILD

Patient’s Name:*

Today's date:

Parent / Guardian:

Relationship to Patient:

Address:

Postal Code

Phone: Home*

Work:

Cell:

Date of Birth:

Sex:

M
F

Email Address:*

Emergency Contact:

Phone*

Physician:

Phone

Previous Dentist:

Phone

HOW DID YOU HEAR ABOUT OUR CLINIC?

Medical History

Has your child seen a doctor , in the past year,

Yes
No

for what reason?

Does your child have any drug allergies that you are aware of?

Yes
No

Please list

Does your child have a Latex Allergy?

Yes
No

Has your child ever taken (please check):

Penicillin
Erythromycin
Sulfa Drugs
Tetracycline
Codeine

Is your child presently taking any Medications?

Yes
No

Please list

HAS YOUR CHILD EVER BEEN TREATED FOR, OR HAD ANY INDICATION OF:

Appointment policy:

we would like to ask for a minimum of 2 BUSINESS DAYS NOTICE If for any reason you will be unable to keep a scheduled appointment. This consideration will allow us to accommodate those patients that may be waiting for an appointment. For your convenience, we will continue to call or email you prior to your appointment to remind you and receive conformation for your visit

I*

have read & understand the above policy, Date*

Signature:

Dental History

Last complete Dental Exam?

Were X-rays Taken

Yes
No

Has your child ever had their teeth cleaned or polished?

Yes
No

Has your child ever had freezing?

Yes
No

Were there any complications?

Yes
No

EXPLAIN:

Do you feel your child's daily dental care is adequate?

Yes
No

EXPLAIN:

How many times per week does your child brush?

How many times do you supervise your child brushing ?

Does your child suck his/her thumb or fingers?

Yes
No

HOW OFTEN?

Has your child ever had a bad experience at the dentist?

Yes
No

EXPLAIN?

How Comfortable would you say your child is with today's visit?

1-APPREHENSIVE 10- EXCITED

Do you have any concerns with your child's teeth?

Yes
No

If your child experiencing any discomfort or pain in his/her teeth?

Yes
No

Is there anything you would like to make us aware of that has not been covered on this form?

Yes
No

(Please list):

PERMISSION TO TREAT/RELEASE OF INFORMATION/PRIVACY

This is to certified that I, The Undersigned,consent to that performance of dental treatment agreed to be necessary of advisable by the dentist. I will assume full responsibility for fees associated with treatment. I authorized release;to my dental benefits and the CDA, information contained i claim submitted electronically. I also authorized the communication of information related to the coverage of services described to the named dentist. The authorization shall continue in effect until the undersigned revoke the same . I am aware the office has a privacy policy which i can view at any time .

Date*

Signature of Patient/Parent/Guardian:*

Dental Insurance

We are more than happy to help you with your insurance claims. Payment in full is required at the time of service , whnever possible , we will electronicaly send your insurance claim, which will speed up the process for yoiu and you should recieve your insurance, reembrancement within few short day.NOTE: Policy holder whose birthday falls first in the year is the "primary policy" holder

primary policy

Name:

DOB:

Provider:

Group #

I.D #

secondary policy