Steeles McLaughlin Family Dentistry

Patient Information Form - Child

18-545 Steeles Avenue West, Brampton, ON, L6Y 4E7      905-455-2023

The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Personal Information

Patient's Name:
Preferred Name:
Patient's D.O.B.
Sex:
Address:
City:
Province:
Postal Code:
Home Number:

Cell Number:

E-mail Address

Best way to contact you?
 
Person to contact in case of an emergency (relationship):

Phone Number:

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number:

Secondary Insurance Company Information

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number:

Referral Information

How did you hear about us? (Check all that apply)

Medical History

Family Doctor:
Phone Number:
Has the child or adolescent every been hospitalized since birth?
At what age(s) and for what reason(s)?
Is a Physician treating the child or adolescent currently?
If yes, for what reason?
Is the child or adolescent taking any medicine currently?
If yes, what are they taking?
Do you have or have ever had any of the following:
YesNo YesNo
Hearing Difficulties Kidney Disease
Speaking Difficulties Epilepsy or Seizures
Emotional Difficulties Cerebral Palsy
Poor Vision Anaemia
Liver Disease or Hepatitis Birth Defects
Diabetes Heart Problems
Bleeding Problems Sickle Cell Anemia
Asthma or Wheezing Rheumatic Fever
Do you or have you ever had any other serious illness not listed above?
If yes, please explain:
Does the child or adolescent have any history of allergies?
YesNo YesNo
Hay Fever Penicillin
Aspirin Local anaesthetic
Sulfa Drugs Other

Dental History

What is your main priority in seeking dental treatment?
Has the child or adolescent ever been to the dentist?
if yes, state whether it was the family dentist or specialist below:
Family Dentist - Name:
Specialist - Name:
Have you been pleased with the child’s or adolescent’s previous dental care?
If no, please comment:
Have the teeth of the child of adolescent ever been injured?
What was the cause of the accident?
How old was the patient?
Which teeth were involved?
Has the child or adolescent had an unfavourable experience in a dental or medial office?
If yes, please describe:
Name of School:
Grade:
Is there any other any other information you would believe to be helpful to us?
If yes, please comment:

Privacy & Release Information

Release of Information: I authorize Steeles McLaughlin Family Dentistry to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history friom my physician, another dental office, insurance company.
Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be necessary to charge for the time lost.
Patient Release: I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

Signature