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Pediatric Patient Intake Form

Dr. Saina Shirazi

Please fill in as much information as possible.

Date of Birth
Year
Month
Day
Address

MCP DECLARATION

Your provincially funding Children and Adult Dental Plan (MCP) provide coverage for eligible services. To help in financially supporting this program we require that you fill out this simple form.

Do you have individual or family insurance coverage outside the Provincial Dental Health Plan? (MCP)
Yes
No
Are you a CDCP member? (Canadian Dental Care Plan)
Yes
No
Do you have dental insurance?
Yes
No

HEALTH INFORMATION

Have you had a serious illness or are you under the care of a physician?
Yes
No
Have you been diagnosed with ADHD or Autism?
Yes
No
Have you ever had an unusual reaction to any drugs or medications?
Yes
No
Are you sensitive or allergic to any drugs or medicines?
Yes
No
Have you ever had an unusual reaction to medication?
Yes
No
Are you taking any medicines or tablets?
Yes
No
Do you have a tendency to faint?
Yes
No
Do you bruise easily or bleed abnormally?
Yes
No
Are you pregnant?
Yes
No
Do you have heart disease or murmur?
Yes
No
Do you have or have you ever had any of the following? (Check all that apply)

DENTAL HISTORY

Have you had a complete dental exam with a full series of x-rays within the last 3 years?
Yes
No
Do your gums bleed when you brush?
Yes
No
Do any of your teeth ache?
Yes
No
Have you ever had teeth extracted?
Yes
No
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