Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Child Patient Information Form Child Patient Information Child's name Last Child's First Date of Birth Address Postal Code Phone (home) Phone (other) Ideal mode of contact Home Work Cell Email Person responsible for the child's account Parent/Guardian's name Employed by Phone (work) Insurance carrier Plan ID Subscriber’s date of birth Whom may we thank for this referral? Medical History Physician's name Has your child ever had any serious illnesses or operations? Yes No Is your child presently under any medical treatment? Yes No Is your child taking any medications at present or recently? Yes No Has your child taken any Steroids or Cortisone in the last three years? Yes No Does your child suffer from any allergies? Yes No Is you child prone to prolonged bleeding? Yes No Have you been told your child needs antibiotics before dental treatment? Yes No Has your child ever had any of the following (please check where applicable) Heart disease Diabetes High/Low Blood Pressure Epilepsy HIV/AIDS Hepatitis Cancer Rheumatic Fever Asthma There is a $75.00 charge for appointments that are cancelled with less than 48 HOURS NOTICE (2 Full Business Days) Archibald Dental Centre is happy to help you receive your maximum dental benefit provided under your insurance plan. The amount of coverage you receive is dependant on the agreement between your employer and the insurance company. However, there are many different plans available and we cannot be experts on all of them. As a patient, I understand that I am financially responsible for the entire treatment or any portion not covered by insurance and that payment is due on the date of service. Parent/Guardian Signature Clear Date reCAPTCHA If you are human, leave this field blank. Submit Δ Patient Information Forms Fill out a patient information form before your first visit. Adult Form Child Form Book Your Dental Care Today! New Patient Check Up & Cleaning Existing Patient Check Up & Cleaning Contact Us
