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Pediatric Dental Intake
For a parent or guardian to complete before your child's first visit.
Child's full name
*
(required)
Date of birth
*
(required)
Parent or guardian name
*
(required)
Email address
*
(required)
Phone number
*
(required)
Doctor's practice
Health
Does your child have any of these?
*
(required)
Asthma
Heart condition
Epilepsy
Diabetes
Bleeding disorder
Additional needs or autism
Hearing or sight difficulty
None of these
Medication your child takes
Allergies
*
(required)
Teeth and habits
Has your child seen a dentist before?
*
(required)
Select…
No, this is the first time
Yes, within a year
Yes, over a year ago
Yes, but it didn't go well
Any of these?
Thumb or finger sucking
Dummy or pacifier
Bottle at bedtime
Grinding at night
Mouth breathing
None of these
How often are teeth brushed?
*
(required)
Select…
Twice a day
Once a day
Sometimes
It's a battle
How often are sugary drinks or snacks had?
*
(required)
Select…
Rarely
Once a day
A few times a day
Throughout the day
Anything you've noticed?
*
(required)
A hole or dark spot
Toothache
Swelling
Chipped tooth
Teeth coming through oddly
Nothing - just a check
How we can help
How does your child feel about coming?
*
(required)
Select…
Fine
A bit nervous
Very anxious
They don't know yet
What helps your child cope?
Anything that went badly before?
I am the parent or legal guardian and consent to my child being examined
*
(required)
Leave this field empty
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