1295 Riverbend Road Suite 260
Do you have dental insurance?
If YES, complete the following
Has there been any change in your general health?
Is your child being treated for any medical condition or have you been treated within the past 2 years?
Is your child currently being treated by a physician for a specific condition?
Is your child currently taking any medication?
Do you bleed or bruise easily?
Have you ever been hospitalized?
Has your child ever received general anesthesia?
Has your child ever had an adverse reaction to local anesthetic?
Does your child have any allergies to medications?
Does your child have any other allergies?
Does your child currently have any of the following conditions?
High Blood Pressure
Artificial Joint Replacement
Is there anything else the doctor needs to know regarding your child's medical health?
Has your child ever been to the dentist before?
Is your child currently experiencing any pain or discomfort?
Are any of your child's teeth sensitive to
Does your child have difficulty chewing food or does food get stuck between his/her teeth?
Has your child ever had an injury to his/her jaw or face?
Has your child been examined by an ORTHODONTIST regarding growth patterns and development?
PATIENT CERTIFICATION AND CONSENT
I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.
SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)
To be signed at your appointment
1295 Riverbend Road Suite 260 London, Ontario
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