4214 66 St NW, Edmonton, AB T6K 4A2 587-404-7677 780-463-8803 info@edmontonsmiles.net

Dr. Molly Rodgers Pediatric Patient Information Form

Please fill out our form below or click on the button to the right to download

Are you aware of your child having any particular dental problems?
YesNo
Is your child having any dental discomfort or pain?
YesNo
Is this your child's first visit to a dental office?
YesNo
Has your child had any bad dental experiences?
YesNo
Is your child allergic to any food or drugs?
YesNo
Has your child ever been hospitalized?
YesNo
Is your child suffering from a serious illness or disease at the present time?
YesNo
Is your child taking drugs or medications at the present time?
YesNo
Has your child ever had:
Heart troubleLung troubleHigh blood pressureRheumatic feverScarlet feverKidney troubleLiver troubleBlood disordersAnemiaJaw injuryDiabetesThyroid troublePneumoniaAsthmaCancer
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.

Insurance Information

Secondary Insurance

Photo/Release Form

Adult Release:
I, the undersigned, herby give permission of images of myself, 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 any social media deemed applicable. I consent to such uses and hereby weave all rights to compensation.
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.

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