Child patient form Patients Name Date Address Phone: Birthdate Parent Name Business Phone: For preferred Trillium Dental Location, please select from dropdown list below: Select locationKeswickBradfordOrangeville How did you hear about our office? Please check any of the following that apply: Orthodontic Treatment (braces)?Root Canal and/or a Crown?Bite adjusted?Bleeding of their gums when brushing or flossing?Oral Surgery (extractions)?Clenching or grinding problems?A negative experience at a dental office? Is another member of your family, or a relative a patient at our office? Their name: Is this your child's first visit to the dentist? Date of your child's last visit to the dentist: Date of your child's last dental xrays: Date of your child's last dental cleaning: Does your child have any sensitive teeth to hot/cold/sweets to bite on? Does he or she suck on their thumb? Has your child ever had any of the following? Checkbox Orthodontic Treatment (braces)?Root Canal and/or a Crown?Bite adjusted?Bleeding of their gums when brushing or flossing?Oral Surgery (extractions)?Clenching or grinding problems?A negative experience at a dental office? Does your child have or have they ever had any of the following? Please check any of the following that apply: Artificial Heart ValveHeart MurmurHeart SurgeryHeart PacemakerHigh Blood PressureRheumatic FeverEpilepsy or SeizuresFainting or Dizzy SpellsBruise EasilyDiabetes: Diet or Medication controlledHepatitis AHepatitis BIt has been suggested that your child neds pre-medication prior to dental treatment. For Parents Do you brush your child teeth? Does your water contain fluoride? Has your child been under medical care during the past two years? Is your child now taking medication? If yes, please list: Has your child had an adverse reaction to any medications? If yes, please explain: Dental Insurance Do you have dental insurance? Primary Policy Holder Insurance Company Secondary Policy Holder Parent Name ( required for under 18 years ) Parent Signature ( required for under 15 years of age )* Clear Use your mouse or finger to draw your signature above
