Child registration

Thank you for your interest in our practice! Would you be so kind as to send us your old dental file for the first appointment? As soon as you have been with us for an intake and it clicks with the practitioner, you are officially registered as a patient.

First name

Surname

Date of birth

Address

City

Zip

Phone

Citizen Service Number (BSN)

Doctor

Previous dentist

Has your child had cavities in the last 2 years?

Are there teeth or molars sensitive with eating, drinking or brushing your teeth?

Are there any specifics regarding the change of milk teeth?

Does your child go to the orthodontist?

Has your child ever fallen on the front teeth or chin?

Are there other things we can take into account?

Is your child allergic to something?

Has your child been breastfed?

Was your child born with a heart defect?

Does your child have an epilepsy diagnosis?

Does your child have asthma, COPD, or another chronic lung disease?

Does your child have diabetes?

Does your child have anemia?

Does your child have hepatitis or other liver disease?

Does your child have kidney disease?

Does your child have stomach or bowel problems?

Are there behavioral problems? (such as anxiety or hyperactivity)

Does your child attend special education or medical day care?

Is your child currently on medication?

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