Parent or Guardian's Name
Date Format: MM slash DD slash YYYY
Parent's Home Phone
Parent's Work Phone
Select a Choice
Is there anyone else in your household that is a patient here?
Can you give us their name please?
Person to Contact in Case of Emergency
Relationship to Patient
How Did You Hear About Us?
Please tell us the name of the family or friend who referred you.
How would you prefer your appointment reminders?
Do you have insurance that covers this child?
Do you have secondary insurance?
Patient Medical History
Physician's Office Phone
Is the child currently under any medical treatment?
Has the child been admitted to a hospital or needed emergency care during the past two years?
Is the child currently taking any medications, including over the counter medications?
Has the child ever had any complications following dental treatment?
Do you have or have had any of the following? Please check all that apply.
High Blood Pressure
Do you have any allergies to medications?
Patient Dental History
Check All That Apply
Gums bleed while you brush
Your teeth are sensitive to hot or cold liquid/foods
You feel pain in any of your teeth
Have any sores/lumps in your mouth
Have any head, neck or jaw injuries
Ever experience any clicking or pain in the TMJ area, difficulty opening or closing
Have frequent headaches
You clench or grind your teeth
You bite your lips or cheeks frequently
Had any difficult extractions or prolonged bleeding from it in the past
Had any orthodontic treatments
You wear dentures or partials
Upload a Photo
We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.
I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Beacon Smiles Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.
I have read the above conditions of treatment and payment and agree to their content.