New Patient Form - Child

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?

Weeks at birth?

Twins?

Breastfed?

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

Main member of medical aid / Person responsible for account

Full name

ID number

Postal Address

Home phone

Cell phone

Email address

Medical Aid

Medical Aid name

Medical Aid number

Nearest relative/ friend name

Contact number

Do you have a booking?

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

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