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Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Menu
Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Book Now
Children's New Patient Form
"
*
" indicates required fields
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- Personal Information
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Name
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First Name
Last Name
Date of Birth
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Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Parent Email
*
Enter Email
Confirm Email
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 our office?
*
Google Ads
Google Maps/Google Search
Billboard Signs
I Live Nearby
Referred By Friend
Social (Facebook, Instagram & Youtube)
Who referred you to our office?
*
We would like to thank the patient that referred you to our office.
Do you have Dental Insurance?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
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Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Do you have a second Insurance Provider?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
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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
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
Please select each Medical Condition that is applicable for you!
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
When was your child's last visit with the physician?
*
Name of Physician
Physician's Phone Number
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 Dental Now Panorama to preform any necessary dental services that I may need.
Signature
*
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Thanks For Filling Out Our Form.