Mer Bleue Dental Centre The Orléans Dental Experience Request an Appointment Children Patient Form Patients Name* First Last Date* MM slash DD slash YYYY Address* Street Address City*Phone*BirthDate* MM slash DD slash YYYY Parent Name* First Last Primary Phone Number:*Work Phone Number:Home Phone Number:Best way to contact you:* Home Primary Work How did you hear about our office?*Please check any of the following that apply:* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Is another member of your family, or a relative a patient at our office?*Their name:*Is this your child's first visit to the dentist?*Date of your child's last visit to the dentist:*Date of your child's last dental xrays:*Date of your child's last dental cleaning:*Does your child have any sensitive teeth to hot/cold/sweets to bite on?*Does he or she suck on their thumb?*Has your child ever had any of the following?* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Does your child have or have they ever had any of the following?* Artificial Heart Valve Heart Murmur Heart Surgery Heart Pacemaker High Blood Pressure Rheumatic Fever Epilepsy or Seizures Fainting or Dizzy Spells Bruise Easily Diabetes: Diet or Medication controlled Hepatitis A Hepatitis B It has been suggested that your child needs pre-medication prior to dental treatment. None of the above Please check any of the following that apply:For ParentsDoes your child need aid when brushing their teeth?*Does your water contain fluoride?*Is your child currently taking any prescribed medications?*Has your child ever reacted to any type of medications?*Has your child had any serious injury/illness within the past two years that required medical attention?*Dental InsuranceDo you have dental insurance?*Primary Policy Holder*Insurance Company*Secondary Policy Holder*Parent Name ( required for under 18 years )* First Last Parent Signature ( required for under 15 years of age )*Use your mouse or finger to draw your signature above
