New Patient Form - Child

About your Child

Patient History

Dental History

Medical History

Person responsible for account

About your child

Child's name

Name child prefers to be called

Date of Birth

School and grade

Hobbies/ Pets/ Likes

Patient History

Maternal age at birth of child?

Any major illnesses/ medication when pregnant?

Medication?

Weeks at birth?

Twins?

Yes No

Breastfed?

Yes No

Breastfed until?

Post-natal health (up to one year) sicknesses and medications:

Sickness/ Medication after one year

Hospitalizations?

Ear, nose and throat issues?

Asthma (medication?)

Reflux?

Chronic blocked nose?

Current medications?

Other significant

dental history

Is this the first visit to the dentist?

Yes No

How was the experience?

Hospitalizations?

What was done in the first visit?

Do you expect your child to be cooperative?

Yes No

Any reason why?

Has your child sustained any injuries to any teeth?

How often does your child brush and do you supervise?

Approximate age when first tooth erupted?

Previous Dental experiences?

Habits

Did/Does your child take a Bottle to sleep? Dummy? Thumb? Mouth breathing? Grinding? Others?

Specify

Medical History

Name of family doctor and contact details

Is your child under supervision for any medical condition?

Yes No

Specify

Is your child in good health?

Yes No

Specify

Any Allergies

Yes No

Specify

Have your child’s adenoids/ tonsils been removed? Please specify any other surgeries or hospitalizations.

Please indicate if your child has any of the following:

Rheumatic fever Anaemia Bone disorder HIV positive Diabetes Epilepsy/ Seizures Bleeding disorders TB Endocrine disorders Cleft palate Asthma Liver problems/ Hepatitis Cancer/ leukaemia Speech problems ADHD Cardiac problems/ heart murmurs Other

Physical Handicap

Yes No

Specify

Mental handicap

Yes No

Specify

Other

Yes No

Specify

Main member of medical aid / Person responsible for account

Full name

ID number

Postal Address

Home phone

Cell phone

Email address

Medical Aid

Yes No

Medical Aid name

Medical Aid number

Option

Nearest relative/ friend name

Contact number

Do you have a booking?

Yes No

Please specify Doctor:

Date

Time

I understand that the above information is accurate.

I understand the above and comply with the conditions of Wiggly Teeth.

We are a private practice. The account needs to be settled in the rooms after each appointment. A major portion can be claimed back from the medical aid by member. We don’t claim from medical aid.

I do herby authorize and consent to the use of photographs of my / my childs’ teeth taken by Wiggly Teeth Dentistry. I grant them permission make use of photographs taken of me / my child for marketing material for website, social media and/or educational purposes.

Yes No

I further understand that if the photography is used that my / my childs’ name and or other identifying information will not be used. No full-face images will be used.

Yes No

I further acknowledge my participation in voluntary and that I will not receive any compensation, financial or otherwise, with respect to the taking, use or publication of these images. I acknowledge and agree that these images confer no rights of ownership or royalties whatsoever.

Yes No

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