General Information

Patient's Name:

Gender:
Male Female

Patient's D.O.B.

Name of Father / Guardian:

Name of Mother / Guardian:

Address:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Work Phone:

E-mail Address

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

Internet - Website/search engine source:

 

Insurance / Financial Information

The following applies to patients with dental insurance:

For your convenience, our office is equipped for electronic claims submissions so that we can expeditiously estimate insurance coverage and process claims. Your insurance plan is a contract between you and your insurance company. Therefore, and like most specialty practices, we do not accept direct payment from your insurance company. We ask that payments be made at the end of each appointment, and will do our best to make sure that you are reimbursed quickly by your insurance company.

Primary Dental Insurance

Secondary Dental Insurance

Insurance Co. Name
Name of Policy Holder
Employer Name
Employer Phone #
Group Policy Number
Member ID #
Date of Birth:

Insurance Co. Name
Name of Policy Holder
Employer Name
Employer Phone #
Group Policy Number
Member ID #
Date of Birth:

Medical History Information

Name of Pediatrition or Family Doctor:

Address:

Phone Number:

Date of Last Physical Examination:

Is your child being treated currently, or within the past year, for any medical condition?
Yes No

Are your child's immunizations up to date?
Yes No

If yes, please list.

Has your child ever been hospitilized for any illness or orperation?
Yes No

If yes, please explain.

If yes, please list.

Does your child have currently or a history of any of the following medical conditions? Please select all that apply.

	Yes	No		Yes	No
Anemia or Blood Disorder			Chronic Ear Infections
Immune Disorders (AIDS, HIV, ARC)			Cleft Lip and Palate
Kidney Disease			Asthma
Convulsions/Seizures			Leukemia
ADD / ADHD			Diabetes
Intellectual Disabilities			Autism
Down Syndrome			Neurological Problems
Behavioral Disorder			Emotional Disturbance
Nutritional Deficiency			Bladder Conditions
Oral Ulcers			Blood Pressure
Excessive Bleeding Problem			Orthopedic Problems
Birth Defects			Excessive Gagging
Premature Birth			Bone or Joint Problems
Fainting or Dizziness			Rheumatic Fever
Brain Injury			Growth & Development Problems
Scoliosis			Bruising or Bleeding Easily
Hearing / Speech Problems			Sickle Cell Trait /
Cancer or Malignancies			Heart Disease
Spina Bifida			Cerebral Disorder
Heart Murmur			Syndrome
Child Abuse			Hemophilia
Tuberculosis			Chronic Adenoid / Tonsil Infection
Hepatitis / Liver Disease

Dental Information

Does your child floss daily?
Yes No

If yes, describe.

Does your child have any of the following mouth habits?

	Yes	No		Yes	No
Pacifer			Finger Sucking
Thumb Sucking			Tongue Thrusting
Lip Sucking			Mouth Breather
Teeth Grinding

Does your child receive fluoride in any of the following forms?

	Yes	No		Yes	No
Vitamins			Water Supply
Tooth Paste			Rinse / Gels
Tablets / Drops

How do you expect your child to react to today's visit?

Excellent Good Fair Poor Don't Know

How may we help to make this a positive experience for your child?

Consent for Dental Treatment

Please read this form carefully before signing. Prior to starting any treatment, we will confirm that you understand treatment options, including risks, benefits, and alternatives. If you have any questions, please ask.

Diagnosis

In order for our dental team to properly diagnose your child’s dental and oral health condition, the following may be necessary

• Dental and oral examination
• Radiographs (x-rays) to diagnose and treat dental conditions as well as growth and development
• Photographs

Prevention

To optimize your child’s oral health condition and to reduce the risk of disease and dental decay, the following treatment may be rendered

• Prophylaxis (cleaning)
• Fluoride application
• Dental Sealants

Treatment

Common dental treatment for pediatric patients includes

• Composite restorations (white fillings)
• Stainless steel crowns (for teeth that have significant decay and/or were treated with pulpotomies)
• Pulp therapy (nerve treatment may include pulpotomies or pulpectomies [root canals] to treat teeth with deep decay or that were traumatized)
• Extraction (may result in damage to adjacent and/or permanent teeth, pain, swelling, bleeding, nerve/jaw damage)
• Space maintainer appliances - appliances made to hold space when primary (baby) teeth are lost early
• Nitrous Oxide “laughing gas” Inhalation – may be used to help a child relax and cope with dental treatment. May result in nausea, vomiting, tingling of the hands and feet.

Behaviour Management

Dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age. Dr. Fini will provide an environment that will help children learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments, and using variable voice tones.

Restraint / Immobilization–for the patient’s safety to reduce unwanted movement, Dr. Fini and her staff may need to use restraint devices (for example, mouth props) or may need to physically hold the child still. Restraint will only be used when absolutely necessary.

Risks of Refusing Treatment

You have the right to refuse treatment; however, delayed treatment may allow for undiagnosed conditions, progression of dental disease, abscess formation, infection, fever, risk of damage to permanent teeth.

Complications of Dental Treatment

The usual and most frequent risks or complications occurring from dental treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury or permanent numbness, and allergic reactions.

Privacy Statement & Consent

Privacy of our patient’s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly.

Personal Information

Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes all that information provided by you to us on our patient information/health/medical history form at the first visit and any subsequent visits. Personal information may also include any information provided by you to us during the normal course of communication between patient and dental office staff. We will use and disclose only information provided to us by you or another person acting on your behalf.

Information Protection

We are committed to protecting your personal information. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft and unauthorized access. Access to your personal information shall be on a “need to know” basis.

Information Disclosure

Your personal information shall be disclosed to only those who have a need to know and them specific information disclosed shall be restricted to only that information relevant to the recipients need to know. Those who have a need to know include other dentists and health care providers (i.e. dental specialists, personal physicians). Further, the personal information disclosed to dental benefit providers is limited to only that personal information required by the provider. You may at any time designate any restrictions as to whom we may disclose your personal information or restrict the content of a disclosure.

Information Retention and Destruction

We will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with provincial or federal regulations or statutes.

Your Access to Your Records

We are committed to providing you with open access to your personal information held by us. You may at any time ask us to see your records held by us and to request amendments to that information. We will provide access to you within a reasonable timeframe recognizing your desire for the information and our need to car y on our practice with limited interruption.

Complaint Process and Contact

Should you wish to make a formal complaint regarding our privacy practices, please do so in writing to our privacy officer, Dr A. Fini. Should you have any questions comments or concerns, please bring them to our attention. We will be pleased to assist you.

Having read and understood the above PRIVACY STATEMENT, I consent to the collection, use and disclosure of my personal information as presented in the statement, subject to the restrictions identified below.

I certify that I have read, understood and accurately completed the personal, medical, and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. If required, I consent to my physician being contacted regarding and specific medical question. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.