New Patient Form Additional Child Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply. 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 PhoneParent's Work PhoneEmail* Select a Choice*MaleFemaleIs there anyone else in your household that is a patient here?*YesNoAddress/ City /Prov /Postal code* Street Address City State / Province / Region ZIP / Postal Code 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 SelectFamily/FriendWebsitePublicationYellow PagesRadioE-BrandonOtherPlease 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?*YESNODo you have secondary insurance?*YESNOPatient Medical HistoryPhysician*Physician's Office PhoneIs the child currently under any medical treatment?*YESNOHas the child been admitted to a hospital or needed emergency care during the past two years?*YESNOIs the child currently taking any medications, including over the counter medications?*YESNOHas the child ever had any complications following dental treatment?*YESNODo 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?*YESNOPatient Dental HistoryCheck 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 PhotoWe 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 South Airdrie Smiles 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.