#850, 6700 – 46 Street Olds, Alberta T4H 0A2
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(587) 855-4747
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New Patient Form Child
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New Patient Form Child
Dentists Olds Alberta New Patient Form Additional Child
Patient Information (Confidential).
All fields are mandatory, please enter n/a if they do not apply.
Name
*
Birth Date
*
Select a Choice
*
Male
Female
Address/ City /Prov /Postal code
*
Parent or Guardian's Name
*
Parent's Home Phone
*
Parent's Work Phone
Email
*
Is there anyone else in your household that is a patient here?
*
No
Yes
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?
*
---
Family/Friend
Website
Publication
Yellow Pages
Radio
E-Brandon
Other
Please 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?
*
No
Yes
Do you have secondary insurance?
*
No
Yes
Address
Street Address
*
City
*
State / Province
*
ZIP / Postal Code
*
Your Country
*
Your Country
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Antarctica
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Austria
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Burundi
Belgium
Benin
Bonaire, Sint Eustatius and Saba
Burkina Faso
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Bulgaria
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Saint Barthélemy
Belarus
Belize
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Bolivia, Plurinational State of
Brazil
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Bouvet Island
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Central African Republic
Canada
Cocos (Keeling) Islands
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Chile
China
Côte d'Ivoire
Cameroon
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Congo
Cook Islands
Colombia
Comoros
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Cuba
Curaçao
Christmas Island
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Cyprus
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Germany
Djibouti
Dominica
Denmark
Dominican Republic
Algeria
Ecuador
Egypt
Eritrea
Western Sahara
Spain
Estonia
Ethiopia
Finland
Fiji
Falkland Islands (Malvinas)
France
Faroe Islands
Micronesia, Federated States of
Gabon
United Kingdom
Georgia
Guernsey
Ghana
Gibraltar
Guinea
Guadeloupe
Gambia
Guinea-Bissau
Equatorial Guinea
Greece
Grenada
Greenland
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Guam
Guyana
Hong Kong
Heard Island and McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Isle of Man
India
British Indian Ocean Territory
Ireland
Iran, Islamic Republic of
Iraq
Iceland
Israel
Italy
Jamaica
Jersey
Jordan
Japan
Kazakhstan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Saint Kitts and Nevis
Korea, Republic of
Kuwait
Lao People's Democratic Republic
Lebanon
Liberia
Libya
Saint Lucia
Liechtenstein
Sri Lanka
Lesotho
Lithuania
Luxembourg
Latvia
Macao
Saint Martin (French part)
Morocco
Monaco
Moldova, Republic of
Madagascar
Maldives
Mexico
Marshall Islands
Macedonia, the former Yugoslav Republic of
Mali
Malta
Myanmar
Montenegro
Mongolia
Northern Mariana Islands
Mozambique
Mauritania
Montserrat
Martinique
Mauritius
Malawi
Malaysia
Mayotte
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Niger
Norfolk Island
Nigeria
Nicaragua
Niue
Netherlands
Norway
Nepal
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Oman
Pakistan
Panama
Pitcairn
Peru
Philippines
Palau
Papua New Guinea
Poland
Puerto Rico
Korea, Democratic People's Republic of
Portugal
Paraguay
Palestine, State of
French Polynesia
Qatar
Réunion
Romania
Russian Federation
Rwanda
Saudi Arabia
Sudan
Senegal
Singapore
South Georgia and the South Sandwich Islands
Saint Helena, Ascension and Tristan da Cunha
Svalbard and Jan Mayen
Solomon Islands
Sierra Leone
El Salvador
San Marino
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Saint Pierre and Miquelon
Serbia
South Sudan
Sao Tome and Principe
Suriname
Slovakia
Slovenia
Sweden
Swaziland
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Seychelles
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Turks and Caicos Islands
Chad
Togo
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Tokelau
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Tonga
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Turkey
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Tanzania, United Republic of
Uganda
Ukraine
United States Minor Outlying Islands
Uruguay
United States
Uzbekistan
Holy See (Vatican City State)
Saint Vincent and the Grenadines
Venezuela, Bolivarian Republic of
Virgin Islands, British
Virgin Islands, U.S.
Viet Nam
Vanuatu
Wallis and Futuna
Samoa
Yemen
South Africa
Zambia
Zimbabwe
Patient Medical History
Physician
*
Physician's Office Phone
Is the child currently under any medical treatment?
*
No
Yes
Has the child been admitted to a hospital or needed emergency care during the past two years?
*
No
Yes
Is the child currently taking any medications, including over the counter medications?
*
No
Yes
Has the child ever had any complications following dental treatment?
*
No
Yes
Do 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
Are they pregnant?
*
No
Yes
Do they have any allergies to medications?
*
No
Yes
Patient Dental History
Check 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 photo
We 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 West Olds Dental 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.
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