Welcome to the family.
Before your child's first visit, please fill out our New Patient Form. It covers the medical and dental history we need to provide safe, personalized care. The office reviews every form before the appointment so the chair time is spent with your child, not on paperwork.
Four steps, ten minutes at home.
Most families finish the form in well under fifteen minutes when they have insurance details and medications handy.
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Download the form
Two pages of patient info, medical and dental history, plus a privacy consent page. Print at home or fill on screen.
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Fill it out at home
You will move through the form faster with everything in front of you. Take your time and answer what you can.
- 03
Email or bring it in
Email the completed form to office@durhamkidsdentistry.com or bring the printed copy to your appointment.
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We review before the visit
The office reviews every form before the appointment and may call to confirm a detail or two so your time in the chair is for your child, not paperwork.
A complete picture of your child.
The form gathers the same history any pediatric dentist needs to plan safe, personalized care. Have these ready and the form will go quickly.
Child's information
- Full name, date of birth, gender
- Address, city, postal code, phones, email
Parents and physician
- Mother's and father's names, occupations, work phones, email
- Family physician or pediatrician with office phone
- Previous family dentist with office phone
Insurance
- Insurance company, policy number, certificate number
- Subscriber's name, date of birth, employer
Medical history
- Vaccine status and regular medical check-ups
- Current medications and supplements
- Allergies to medications, foods, or environmental sources
- Hospitalizations, surgeries, general anesthetic history
- Bleeding or clotting, cardiac or respiratory conditions
- Developmental, attention, language, social, or learning notes
- Other conditions and habits (checklist on the form)
Dental history
- Last dental visit and any specific concerns
- Oral habits (thumb or lip sucking, soothers, nail biting)
- Previous dental trauma or mouth injuries
Emergency contact + signatures
- An emergency contact's name, relationship, phone
- Parent or guardian signature on patient information and privacy consent
The small print, in plain English.
Scheduling
Your appointment time is reserved specifically for you and your child. We are happy to reschedule without a fee up to 48 hours in advance. We make every effort to keep appointments on time, and we ask you to arrive promptly so we can do the same for the family after you.
Financials
The 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. 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 ask the front desk if this is necessary.
Privacy of your child's information
Privacy of your child's personal health information is an important part of our office providing quality dental care. The form's consent section explains how information is collected, used, and disclosed, in line with the Regulated Health Professions Act and the standards of our regulatory body, the Royal College of Dental Surgeons of Ontario.
Dr. Evan Zaretsky is the office's contact person for personal health information matters. You may withdraw consent at any time. See our privacy policy for the full text.
If this is a dental emergency
Please do not wait for paperwork. Call us right away and we will fit your child in during clinic hours.
Ready when you are.
Our office will review your form and may try to contact you before the appointment to confirm a few of your answers. If you have a question before you sit down with the form, we are happy to help.