Child Registration Form

Child's Full Name:

Date Of Birth:

Child's Age:

Sex:

Po Box:

Post Code:

Mothers Name:

Mothers Mobile phone:

Mothers Email Address:

Fathers Name:

Fathers Mobile phone:

Fathers Email Address:

Doctors Name:

Doctors Phone Number:

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship to child:

Child on any medications?

Yes

Please specify Medications:

Does your child have any Allergies?

Yes

Please specify Allergies:

Does your child have any Medical conditions?

Yes

Specify Medical Conditions:

Is your child allergic to any medications?

Yes

Please specify Allergies

Child first visit?

Yes

Date Of Last Visit:

Date Of Last X-rays:

How often does your child brush?

How often does your child Floss?

Child's degree of nervousness about undergoing dental treatment:

None

Slight

Mild

Very

General Release

I authorize the dentist/ hygienist to perform diagnostic procedures and treatment as may be required for proper dental care.
I authorize the release of any information concerning my (or my child’s) health care, advice and treatment to another medical/dental professional.
I authorize the setting up of my dental file, its follow-up, as well as my registration on any recall list(s) of the treating dentist(s).
I understand I am financially responsible for payments in full of all accounts at the time of my appointment. By signing this statement, I agree to be responsible for payments of all services
I understand that my file will always be kept in the office and only the dentist(s) and his/her/their auxiliary personnel will have access to it.
I attest to the accuracy of the information on this registration form.

Medical/Dental Informed Consent

I, the undersigned, certify that I have provided, to the best of my knowledge, an accurate and complete medical and dental history and have not knowingly omitted any information. I consent to my dentist obtaining from other practitioner who are currently treating me or have treated me, such further information as may be necessary for providing me with proper dental treatment and care.
I hereby commit to informing my dentist of any changes to my health status.

Appointments

Your appointment has been reserved just for you. Our intention is to respect your time by being on time. In keeping with this promise, a commitment on your part is needed to secure your appointments.

All cancellations, changes or alterations must be made within 2 business days’ notice. If your appointment is over two hours, 4 business days’ notice must be given.
If you fail to attend your appointment without proper notice, we may require a deposit for you to book another appointment.

Insurance

I understand that I am responsible for my dental cost regardless of any insurance coverage. I understand that I am responsible for being aware of my policy and its coverage limits. (We will do our best however to work within the limits of your policy).

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

First Name:

Last Name:

Today's Date:

Anything else you’d like us to know: