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New Patient Form

Please fill out and sign the new patient form

    Child's Name:*
    Gender:
    Date of Birth:
    Manitoba Health Registration#:
    PHIN #:
    Mailing Address:
    City:
    Province:
    Postal Code:
    Home Phone:
    Cell Phone:
    Emergency Phone:*
    Who will accompany the child?
    Do you have legal custody rights?
    How did you hear about Just4Kids Dental?
    If other, please specify:
    Name:
    Marital Status:
    Date of Birth:
    Relationship to Child:
    Lives with Child:
    Mailing Address:
    Employer:
    Work Phone:
    Mobile Phone:
    Email:
    Name:
    Marital Status:
    Date of Birth:
    Relationship to Child:
    Lives with Child:
    Mailing Address:
    Employer:
    Work Phone:
    Mobile Phone:
    Email:
    Subscriber:
    Relationship to Child:
    Insurance Company:
    Policy/Group #:
    Contract/ID #:
    Status #:
    Subscriber:
    Relationship to Child:
    Insurance Company:
    Policy/Group #:
    Contract/ID #:
    Status #:
    Why did you bring your child to us today?
    Is this your child's first visit to a dentist?
    If you answered No the previous question, please provide information below:
    Previous dentist:
    Date of last visit:
    Were there any X-rays taken?
    Has your child had any problems with previous dental care?
    How do you expect your child to co-operate for dental treatment?
    Does your child currently have a tooth ache?
    Have there been any injuries to the teeth?
    If Yes, please explain:
    Is the water your child drinks fluoridated?
    How often are your child’s teeth being brushed?
    Flossed?
    Name of Pediatrician/family physician:
    Is your child taking any medications
    If yes, please state list and why:
    Has your child ever had a bad reaction to drugs, including antibiotics or local/general anesthetics?
    Has your child ever had surgery or been hospitalized?
    If yes, please explain:
    Are antibiotics required prior to dental treatment?
    Does your child have or ever been diagnosed with any of the following conditions? (Please check)
    If Yes, please explain:
    Does your child have any allergies?
    If Yes, please explain:
    By signing this form electronically, I declare and certify that I have read and understand the above questions. If I had questions about this form, they were answered to my satisfaction. I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions that may have been made in completing this form. Please use your computer mouse or mobile touch screen to sign this form in the box below:
    Date: Please click the submit button to send the form