New Patient Form - Child ⋆ Wiggly Teeth

About your child

Child's name

Name child prefers to be called

Date of Birth

School and grade

Hobbies/ Pets/ Likes

dental history

Is this the first visit to the dentist?

Yes No

What was done in the first visit?

Do you expect your child to be cooperative?

Yes No

Any reason why?

Does your child suck his/her fingers/thumb?

Yes No

Has your child sustained any injuries to any teeth?

Does your child take a bottle to bed?

Yes No

How often does your child brush and do you supervise?

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

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.

Submit

The form was sent successfully.

An error occured.

Contacts

Useful links