Name
*
First Name
Last Name
Parent or Guardian's Name
*
First Name
Last Name
Birth Date
*
Date Format: MM slash DD slash YYYY
Parent's Home Phone
Parent's Work Phone
Email
*
Select a Choice
*
Male
Female
Is there anyone else in your household that is a patient here?
*
Yes
No
Can you give us their name please?
*
Person to Contact in Case of Emergency
*
Relationship to Patient
*
Phone Number
*
How Did You Hear About Us?
*
Please Select
Family/Friend
Website
Publication
Yellow Pages
Radio
E-Brandon
Other
Please tell us the name of the family or friend who referred you.
How would you prefer your appointment reminders?
*
Via Mail
Phone Call
Text Message
Do you have insurance that covers this child?
*
YES
NO
Do you have secondary insurance?
*
YES
NO
Patient Medical History
Physician
*
Physician's Office Phone
Is the child currently under any medical treatment?
*
YES
NO
Has the child been admitted to a hospital or needed emergency care during the past two years?
*
YES
NO
Is the child currently taking any medications, including over the counter medications?
*
YES
NO
Has the child ever had any complications following dental treatment?
*
YES
NO
Do you have or have had any of the following? Please check all that apply.
*
AIDS/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizzieness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Mental Disorders
Pacemaker
Radiation Therapy
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Strock
Tuberculosis
Tumors
Venereal Disease
Smoker
None
Do you have any allergies to medications?
*
YES
NO
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
None
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.