Dentistry for Children
Dr. Diederik W. Millenaar
Dr. Gordon Jinks
601-805 West Broadway
Vancouver, B.C. V5Z 1K1
phone: 604-731-4608
fax: 604-733-3031

New Patient Form

Please print out this form, complete it, and bring it with you to our office on your first visit.

Child's Name: ______________________________________________

Date of Birth: __________________ Approx. Weight: ______________


Welcome To Our Office

We are dedicated to preventative dentistry and our aim is to help keep your child's teeth healthy for a lifetime. To help us treat your child, the following information is requested.

Dental History

Is this your child's first visit to a dentist? Yes No
If no, who was the last dentist? ______________________
Was there a problem with cooperation at the last dentist? Yes No
Do you know if your child has cavities now? Yes No
Has your child taken Fluoride pills or drops? Yes No


Medical History
Has your child had any of the following? ( please check if positive.)
Asthma
HIV/AIDS
Blood Disorders
Hospital Surgery (medical or dental)
Extensive Bleeding
Liver or Kidney disease
Diabetes
Medical Condition(s)
General Anaesthetic or Sedation
Rheumatic Fever
Heart Problems
Other _________________
Hepatitis  

Please name any allergies that you are aware of:

_____________________________________________________________________

Please name any medications that your child is currently taking:

_____________________________________________________________________

Are ther any medical problems you would like to comment on? Please describe:

_____________________________________________________________________

Dental Plan Information

As a service to you, we will provide an estimate based on your dental plan to predetermine the level of coverage towards our specialty fees. We will require the following information:
Your plan limit? Per person or per family? ______________________
Percentage coverage (Basic or specialist fees)? ______________________
Do they pay for composite (white) restorations on primary teeth & permanent molars? ______________________
Are your flouride treatments 6 or 9 months apart? ______________________
Is there a deductible? ______________________
Do they pay for oral sedation (code 92422)? ______________________
Are stainless steel crowns covered as basic for primary or permanent teeth? ______________________

As a service to you, we will provide an estimate to your dental plan to predetermine the level of coverage towards our specialty fees. As your dental plan is a contract between you and your carrier, we encourage you to be completely familiar with the terms of your plan. Even though we try to estimate your portion due, the ultimate responsibility for any amount not covered by your plan rests with you.

Patient portion is due in full at the time of service. For your convenience, we accept Mastercard, Visa, debit, and cash. We do not accept cheques.