Child New Patient Intake Form

Child’s information

The following information is required by East Village Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Child’s Name

Child's Name

First

Last

Preferred Name

Date of Birth

Gender

Address

City

State/Province

Zip/Postal

Child Health Care Number

Child Doctor’s Name

Doctor’s Phone

Parent Information

Info of person responsible for payment of account.

Parent’s Name

Parent's Name

First

Middle

Last

Title

Address

City

State/Province

Zip/Postal

Home Phone

Cell Phone

Employer

How do you prefer to be contacted?

How did you hear about us?

This information greatly helps us.

Financing Options

Yes

Hepatitis A B C

Medications

List all medications, supplements, and or vitamins taken within the last two years

Drug:

Purpose

Dosage

Allergies:

Is there anything in your medical or dental history that is not listed and we should know about?

As the parent and/or legal guardian of the patient, I do hereby request and authorize the dentists and staff to examine, clean, and provide dental treatment on my child. I further request and authorize the taking of dental x-rays as may be considered necessary to diagnose and/or treat my child’s dental problem. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behaviour by helping them understand the treatment in terms appropriate for their age. The dentists and staff will provide an environment that will help your child learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments. The usual and most frequent risks or complications occurring from dental operative treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding and allergic reactions.

I understand I will be responsible for any charges incurred for my child for dental treatment. I affirm that the information above is correct to the best of my knowledge. I understand it is my responsibility to inform East Village Dental of any changes in my child’s medical status.

Parent/Guardian Name *

Date

Signature

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Monday	8AM to 8PM
Tuesday	8AM to 8PM
Wednesday	8AM to 8PM
Thursday	8AM to 8PM
Friday	8AM to 4PM
Saturday	830AM to 4PM
Sunday	CLOSED

Child’s information

Parent Information

Medical History

Specific History

Dental History

Medications

Child’s information

Parent Information

Medical History

Specific History

Dental History

Medications

Working Hours