New Patient Form

Please fill out our NEW PATIENT FORM prior to your initial appointment.

Download PDF Form

"*" indicates required fields

Child's Full Name*

Preferred Name*

Age*

Date of Birth*

MM slash DD slash YYYY

Gender*

Home Address*

Street Address City / Town Postal Code

Best Contact Phone #*

Care Card # / PHN*

Insurance*

YES

Child's Physician

Parent 1 / Legal Guardian (Full Name)*

Address (If Different From Above)

Street Address City / Town Postal Code

Phone #*

Email*

Relationship to Child*

Parent 2 / Legal Guardian (Full Name)

Address (If Different From Above)

Street Address City / Town Postal Code

Phone #

Relationship to Child

Dental Insurance Company (1st Carrier)

Insured Name

Date of Birth

MM slash DD slash YYYY

Policy / Group #

Employer ID # / Subscriber ID #

Dental Insurance Company (2nd Carrier)

Insured Name

Date of Birth

MM slash DD slash YYYY

Policy / Group #

Employer ID # / Subscriber ID #

Additional Insurance

Is your child covered under any other benefit plans? (Healthy Kids, FNHA, etc.)

YES

If yes, what is the child’s identification / registration / status #?

Name of Child’s Siblings

Pediatric Dental & Medical History:

These questions are of great value in helping me to better understand your child. All information provided will remain CONFIDENTIAL.

Dental History:

What is the reason for this visit?

When did your child last receive dental treatment?

Have dental x-rays been taken for your child?

YES

If YES, when (approx.)?

Do YOU have any concerns about your child’s mouth/teeth?

Has your child had any unfavorable experiences in a dental/ medical office?

YES

Please Describe:

How would you describe your child's temperament?

Does your child have any of the following habits that might affect his/her teeth or mouth…

Does your child brush his/her own teeth?

YES

How often in a day?

Does your child floss?

YES

Does your child use toothpaste?

YES

Does it contain Fluoride?

YES

Breaths through mouth?

YES

Bites fingernails?

YES

Tongue habits? (sucking/ thrusting)

YES

Grind teeth?

YES

Sucks thumb/ fingers?

YES

Age Stopped

Pacifier ?

YES

Age Stopped

Breastfed?

YES

Age Stopped

Bottle fed?

YES

Age Stopped

Medical History:

The following information is required to enable us to provide your child with the best possible care. Please notify us of any medical changes, allergies, and/or new medications at any time in the future.

Is your child adopted or foster care?*

YES

Were there any problems experienced during pregnancy?*

Did your child have any problems during the 1st year of life? (medical/ dietary)*

Has your child had a personal history of… (check box if YES)

Allergies

Drugs

Environment/ Dietary

Other

Genitourinary Disorder

Bladder

Kidney

Other

Heart Disease

Congenital

Rheumatic

Other

Craniofacial

Cleft lip/ palate

Other

Respiratory Disorder

Asthma

Cystic fibrosis

Other

Endocrine Disorder

Diabetes Type 1

Diabetes Type 2

Other

Gastrointestinal Disorder

Aspiration / Reflux

Feeding Tube

Other

Bleeding / Blood Disorder

Hemophilia

Von Willibrands

Other

Seizure Disorder

Cerebral Palsy

Developmental Delay/ Learning Disorder

Liver Conditions

Behavioral Problems

Malignant Hypothermia

Autism / Spectrum Disorder

Cancer

ADHD

Immunodeficiency

Emotional/ Anxiety Disorder

Transplant

Skin Conditions

Premature Birth

Limitations of arms or legs

Limitations of Arms or Legs

OTHER

Does your child have or has had any medical conditions not listed above?*

YES

If YES, please list:

Has your child ever been hospitalized or had a general anesthetic?*

YES

If YES, please list:

Is your child taking any prescription medications, over the counter medicines, or natural remedies?*

YES

If YES, please list:

CONSENT TO TREATMENT:

It is necessary that a signed permission be obtained from a parent/ legal guardian before any and/or all necessary dental services can be started, because your child is a minor. Authorization is hereby granted as such. If during the course of such treatment, in Dr. Coutu’s opinion and judgment, any treatment or procedure different from that now contemplated should be indicated in respect of which there is no reasonable opportunity for additional explanation and authorization, you can further request and authorize her to do whatever she considers advisable. Furthermore, the individual indicated on this form will be responsible for any account incurred on this child for dental treatment and understand that the account is due at each appointment, or whatever arrangement has been previously mutually agreed upon with Dr. Coutu.

Date*

MM slash DD slash YYYY

Name of Parent / Legal Guardian*

Signature of Parent / Legal Guardian*

Financial Arrangements Approval

Patient

Dr. Coutu is a specialist in Pediatric Dentistry and follows the BC Dental Association's fee guide for specialists. The fees may be higher than those paid by your insurance plan.

Dental estimates: are dependent on the cooperation of the patient, diagnostic radiographs and timely follow through of treatment. A delay of 6 months will require another exam to update the treatment plan. Estimates are honored for 45 days from the date of issue.

Dental insurance: Unlike most specialist offices, we do accept dental coverage. Please check your coverage for annual maximums and if they cover specialist fees. Predeterminations can usually go electronically to 1st carrier, 2nd carrier generally go by regular mail. Response from insurance companies may or may not be sent to our office. If you receive insurance details please share with us so that we can provide you with a more accurate estimate.

Deposits: for hospital treatment that are used in full will be refunded once we have received payment from your insurance company.

In office appointments require 48 hour notice for cancellation. Short notice cancellations and missed appointments are subject to a $100.00 fee.

We accept cash (exact amount), and debit E-Transfers. Mastercard and Visa payments have a 3% charge.

My signature below certifies that I have read and agree to the policies outlined on this form and that I am responsible for the fees associated with my child's treatment.

Signature*

Date*

MM slash DD slash YYYY