New Patient Form In Whitby | Dental and Medial History Form

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Whitby Pediatric Dentist

We understand that trying to find a nearby pediatric dentist you can trust is difficult, that is why we make it easy for you to work with us.

(905) 579-0709

5 - 10 Meadowglen Drive

office@durhamkidsdentistry.com

(905) 579-0709

HOME
ABOUT OUR OFFICE
PATIENT INFORMATION
ORAL HEALTH ISSUES
PROCEDURES WE OFFER
CONTACT
- Patient Referral

New Patient Form In Whitby | Dental And Medical History

Downloadable New Patient Form

Child Information

Child Information

Child First Name

Child Last Name

Child Date of Birth

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Parent/ Guardian Information

Parent/ Guardian Information

Your First Name

Your Last Name

Your Email

Your Phone Number

Your Relationship To Child

How did you hear about us?

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Primary Address Of Child

Primary Address Of Child

Street Address

Unit

City

Province

Postal Code

Country

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Insurance Information

Insurance Information

Does your child have dental insurance?

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If yes, please complete the following questions. If no, move onto Medical History

If yes, please complete the following questions. If no, move onto Medical History

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Insurance Company Name

Certificate / ID Number

Policy Number

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Medical History

Medical History

Family Physician Name

Family Physician Number

Date of last doctor visit

Previous Dentist Name

Previous Dentist Number

Date of last dental visit

Has your child had dental x-rays taken within the last 2 years?

Does your child have any of the following illnesses

Heart disease

High blood pressure

Low blood pressure

Hepatitis A/B/C

Drug addiction

Cold sores

Oral cancer

Have had radiation or chemotherapy

HIV or AIDS

Other sexually transmitted disease

Epilepsy or seizures

Tuberculosis

Diabetes

Stroke

Jaundice

Asthma

Sinus trouble

Snoring

Thyroid disorder

Arthritis

Digestive disorder

Kidney disease

Gastrointestinal disorder

Bleeding disorder or bruise easily

Does your child have any of the following conditions

Facial muscle tenderness

Jaw joint clicking, popping, or locking

Migraines or headaches

Earaches

TMD (jaw pain)

Neck or shoulder pain

Hearing loss

Lumps or sores in their mouth

Teeth grinding

Sore or tender gums

Snoring

Burning sensation on their lips or tongue

Sleep apnea

Dry mouth

Do they smoke

Does your child suffer from any illness or condition not listed? (please list)

Are they allergic to latex?

Are they allergic to metals?

Are they allergic to acrylic?

Please list all medications your child is currently taking

Please list all major injuries and surgeries in the last 10 years

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Opt-In

I hereby certify that all of the information in this form is true to the best of my knowledge and that I have not knowingly omitted any information. By checking, I agree to share my form responses.

Thank you for completing our New Patient Form.

Our office will review your form and reach out to you if we have additional questions. We may try to contact you before your child's scheduled appointment to confirm some of your answers.

Please note, if this is a dental emergency, it would be best to call our clinic as this is the fastest way to reach us (905) 579-0709.

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Call us at (905) 579-0709

We are the local Whitby pediatric dentist near you!

Making kids smile, one tooth at a time

Book Your Child's Next Dental Visit

We look forward to seeing you and your child soon!

Please note, we will try our best to accommodate your schedule.

Child Full Name

Parent Full Name

Parent Phone Number

Parent Email

When would you like to come?

What time of day is better for you?

Please provide more information. How can we help?

Thank you so much for contacting our pediatric dental clinic. While we strive to respond to all inquiries right away, we may be away from the desk helping a patient or out of the office. We will do our best to reach out to you shortly.

Please note, if this is a dental emergency, it would be best to call our clinic as this is the fastest way to reach us (905) 579-0709.

Oops, there was an error sending your message.
Please try again later

Whitby Pediatric Dentist

We understand that trying to find a nearby pediatric dentist you can trust is difficult, that is why we make it easy for you to work with us.

5 - 10 Meadowglen Drive

office@durhamkidsdentistry.com

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Dental Clinic Hours

Monday: 9:00 am - 5:00 pm
Tuesday: 9:00 am - 5:00 pm
Wednesday: 9:00 am - 5:00 pm
Thursday: 9:00 am - 5:00 pm
Friday: Appointment Only
Saturday: Closed
Sunday: Closed

© 2024

All Rights Reserved | Durham Kids Dentistry

© 2024

All Rights Reserved | Durham Kids Dentistry

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