Child Patient Information Form

Child Patient Information
Last
First

Person responsible for the child's account

Medical History

Has your child ever had any serious illnesses or operations?
Is your child presently under any medical treatment?
Is your child taking any medications at present or recently?
Has your child taken any Steroids or Cortisone in the last three years?
Does your child suffer from any allergies?
Is you child prone to prolonged bleeding?
Have you been told your child needs antibiotics before dental treatment?
Has your child ever had any of the following (please check where applicable)
There is a $75.00 charge for appointments that are cancelled with less than 48 HOURS NOTICE (2 Full Business Days)
Archibald Dental Centre is happy to help you receive your maximum dental benefit provided under your insurance plan. The amount of coverage you receive is dependant on the agreement between your employer and the insurance company. However, there are many different plans available and we cannot be experts on all of them. As a patient, I understand that I am financially responsible for the entire treatment or any portion not covered by insurance and that payment is due on the date of service.