We accept the Canadian Dental Care Plan (CDCP) at both our locations. Learn More.

New Patient From

We look forward to welcoming you!

Patient Information

Child's Name(Required)
Child's Gender(Required)
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Child's Home Address(Required)

Insurance Information

Parent / Gaurdian Name(Required)
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Dental Insurance
Parent / Guardian Name(Required)
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Dental Insurance

Medical History

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Please check if your child has been treated for any of the following

Dental History

Consent

As the parent and I or legal guardian of the patient, I do hereby request and authorize the dentists and staff of Dental Care for Children to examine, clean, and provide dental treatment for my child. I further request and authorize the taking of dental x-rays as may be considered necessary to diagnose and / or treat my child’s dental problem. I will allow photographs to be taken of my child or child’s teeth for diagnostic or educational purposes. I understand that dental treatment for children includes efforts to guide their behavior by helping them understand the treatment in terms appropriate for their age, which could or may include, voice control measures to ensure the safety of your child during treatment. Dental Care for Children will provide an environment that will help your child learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments. The usual and most frequent risks or complications occurring from dental operative treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions. I also hereby agree that in the event of a first-aid emergency, the dentists or staff of Dental Care for Children may administer the necessary treatment. I understand I will be responsible for any charges incurred for my child‘s dental treatment. I affirm that the information above is correct to the best of my knowledge. I understand it is my responsibility to inform Dental Care for Children of any changes to my child‘s medical status(Required)
We would like to ask for your cooperation in providing a minimum of two business days notice (48 hours) if for any reason you will be unable to keep a scheduled appointment. This consideration will allow us to accommodate those patients that may be waiting for an appointment. If you are unable to provide notice, there may be a short notice cancellation fee.(Required)
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