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  - Dr. Jeff Bullock
  - Dr. Do Hyun Sung
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Children's New Patient Information Form

Step 1 of 5 - Personal Information

20%

Name*
First Name Last Name
Date of Birth*
Day
Month
Year
Address*
Street Address City Province Postal Code
Emergency Contact*
Emergency Contact Number*
What's your child's main concern right now?*
When was your child's last dental visit?*
Previous Dental Office
How did you hear about us?*
- Google Ads
- Google Maps/Google Search
- Billboard Signs
- I Live Nearby
- Referred By Friend
- Social (Facebook, Instagram & Youtube)

Parent Employer
Parent Occupation
Does your child have dental insurance?
- Yes
- No
Name of Dental Insurance Subscriber
First Last
Date of birth of subscriber
MM slash DD slash YYYY
Name of Insurance Provider
Group/Plan Number
Certificate/ID Number
Does your child have a secondary dental insurance?
- Yes
- No
Name of Dental Insurance Subscriber
First Last
Date of birth of subscriber
MM slash DD slash YYYY
Name of Insurance Provider
Group/Plan Number
Certificate/ID Number

Does your child have any serious Medical Conditions we should know about?*
- Yes
- No
Please explain.
Known Medical Conditions
- Alcohol/ Drug Abuse
- Angina
- Arthritis
- Asthma
- Blood Disorder
- Cancer
- Chemotherapy
- Congenital Heart Defect
- Diabetes
- Dizziness/Fainting
- Emphysema
- Epilepsy/Seizures
- Frequent Headaches
- Gag Reflex
- Hay Fever
- Head Injuries
- Hearing Disabled
- Heart Attack
- Heart Murmur
- Hemophilia
- No Known Medical Issues
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
- Hepatitis A/B/C
- High Blood Pressure
- HIV/AIDS
- Joint Replacement (hip, knee, etc)
- Kidney Disease
- Liver Disease
- Low Blood Pressure
- Lung Disease/ Tuberculosis
- Mental Disorder
- Mitral Valve Prolapse
- Multiple Sclerosis
- Pacemaker
- Radiation Therapy
- Respiratory Problems
- Sinus Problem
- STD
- Stomach/Intestinal Problems
- Stroke
- Thyroid Disorder
- Ulcer
- Other
If Other selected, please specify:*
Does your child have any allergies to medication or substances?*
- Yes
- No
What Allergies do you have?
Is your child taking any prescription medication or herbal remedies?*
- Yes
- No
Please list off your child's medications*
Does your child need to be medicated with antibiotics prior to dental treatment*
- Yes
- No
Has your child been treated for any other illness not listed above?*
- Yes
- No

Has your child recently been under the care of a physician?*
- Yes
- No
Name of Physician
Physician's Phone Number
When was your child's last visit with the physician?*
Current Health Condition*
- Excellent
- Good
- Fair
- Poor
Is there anything else we should know about your child?

Full Name of Legal Guardian/Parent responsible for the form*
First Name Last Name
Consent*
I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize North Stony Dental to preform any necessary dental services that I may need.
Signature*

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2045 Symons Valley Pkwy NW #3010,
Calgary, AB T3P 0Y2

403-452-2833
reception@parkwaysmiles.ca

How Our Dentists Can Help

Invisalign
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Children's Dentistry
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Communities Our Clinic Serves

Evanston
Livingston
Sage Hill
Carrington

About
- Our Office
- Our Team
  - Dr. Jeff Bullock
  - Dr. Do Hyun Sung
Services
Orthodontics
Contact Us

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About
- Our Office
- Our Team
  - Dr. Jeff Bullock
  - Dr. Do Hyun Sung
Services
Orthodontics
Contact Us

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