Dental and medical history.
Our office will review your form and reach out to you if we have additional questions. We may try to contact you before your child's scheduled appointment to confirm some of your answers.
Durham Kids Dentistry New Patient Form
Patient information, medical history, dental history, and the patient consent form.
Download the formFrom the form itself.
Scheduling
Your appointment time is reserved specifically for you and your child. We are happy to reschedule your appointment without a fee up to 48 hours in advance. Please note that we make every effort to keep our appointments on time. To accomplish this we ask that you arrive promptly for your appointment and be understanding that some appointments may run longer than intended, because of the unpredictable nature of pediatric dentistry. We ask you to extend this consideration to other patients and parents as they would for you.
Financials
This office operates on a fee-for-service basis. Payment for the day's treatment is due on the day of treatment and can be paid by debit, credit card or cash. Your dental insurance is a contract between you and your insurance provider and does not involve this office. Our treatment plans are based on your child's dental needs and not insurance coverage. We are happy to help you fill out, and in many cases submit, your insurance claims for you. Alternative arrangements such as direct billing or payment plans may be considered on an individual basis. Please inquire if this is necessary.
Privacy
Privacy of your child's personal health information is an important part of our office providing quality dental care. We understand the importance of protecting this personal health information. We are committed to collecting, using and disclosing this personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information.
Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and local, provincial and federal laws.
Dr. Evan Zaretsky is our contact person for personal health information related matters. You may withdraw your consent for use or disclosure of your child's personal health information at any time. See our privacy policy for the full text.
Dental emergency
Please note, if this is a dental emergency, it would be best to call our clinic as this is the fastest way to reach us.