Fill Pediatric Form - Molly Rodgers Edmonton Dentist

First Name

Last Name

Date of Birth

Patient's Address

City/Town

Postal Code

Parent or Guardian's Full Name

Occupation

Phone #

Patient's School

Grade Level

Physician's Name

Physician's Phone #

Weight

Height

Is your child covered by an insurance plan?

Social Assistance # (if applicable)

Father's Full Name

Father's Occupation

Father's Business Phone Number

Mother's Full Name

Mother's Occupation

Mother's Business Phone Number

Or Legal Guardian's Full Name

Legal Guardian's Occupation

Legal Guardian's Business Phone Number

Is your child having any dental discomfort or pain?

Yes

No

If so, what?

Is this your child's first visit to a dental office?

Yes

No

If not, when was the last dental examination?

Who was your child's last dentist?

Has your child had any bad dental experiences?

Yes

No

Is your child allergic to any food or drugs?

Yes

No

If so, what?

Has your child ever been hospitalized?

Yes

No

If so, what reason?

Is your child suffering from a serious illness or disease at the present time?

Yes

No

If so, what reason?

Is your child taking drugs or medications at the present time?

Yes

No

If so, for what?

For what reason?

If Cancer, what kind?

For what reason?

This is to certify that I, undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable, including the use of local anesthesia and any necessary sedation as indicated. I agree to make payment for services upon completion at each appointment, by cash, cheque or credit card unless other arrangements have been previously and specifically made with the dentist.

I also understand that there will be a charge for appointments missed without sufficient notice.

Parent (or Guardian's) Signature

Date

Is your child covered by dental insurance?

Yes

No

Child Release:

I, the undersigned, am the parent/guardian of the minor child named below and hereby give permission of images of my child, captured during regular activities of the Dr. Molly Rodgers Dental office, through video, still photo, digital imaging or any other such means, to be used for the purpose of advertising, promotion on the company website and social media. I consent to such uses and hereby waive all right to compensation.

Name of Child

Name of Adult or Parent/Guardian

Today's Date

Pediatic Patient Form

Contact Info

Location

Edmonton Smiles

HOurs of Operation

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