Dear Parents,
Since we hope to accompany your child for many years, we want to work together from the very beginning to spark your child’s curiosity and make dental visits as positive as possible. Children are truly bright: if a reward is promised for cooperating, they automatically understand that there is a hurdle to overcome, and that is exactly what can trigger anxiety in the first place. Therefore, please refrain from promising rewards as well as using phrases like “don’t be afraid” or “it won’t hurt.”

Please let us take the lead in communicating with your child, and feel free to encourage them to go into the treatment room with us alone. Please consider whether you wish to accompany your child into the room or encourage them to go alone; it is usually more successful when anxious parents stay outside. We respond to your child’s wishes in a completely child-friendly manner.

Download Offline Application Form of Medical history form for printing
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    MEDICAL HISTORY FORM

    Welcome to our practice!

    Before we take the time to discuss your wishes and concerns, we need your personal details as well as information about your general health. This is important to ensure that your treatment is appropriate and carries as little risk as possible. All information you provide is subject to medical confidentiality.

    Personal Information

    Reason for Today’s Visit*

    Dental Medical History

    Question
    Are you currently experiencing toothache? *
    Do you have bleeding gums or other gum problems? *
    Does your jaw joint click when you chew or yawn? *
    Do you suffer from headaches or neck pain? *
    Do you snore? *
    Are you satisfied with the appearance of your teeth? *
    Do you regularly receive professional dental cleanings? *
    Do you use dental floss or interdental brushes? *
    Has your health changed in the past year? *
    Are you currently receiving medical treatment? *
    If you are receiving medical treatment, what is the reason? *
    Regular Medications *
    General Practitioner / Specialist *
    Allergies / Intolerances (e.g. penicillin, latex, metals)? *

    Previous Dental History

    Question
    Have you had any X-rays taken in the past two years? *
    Have you ever experienced problems with local anaesthesia? *
    Do you currently have any dental prostheses? *
    If yes, please briefly explain / specify when: *
    Other Information About Your Dental History *

    General Health

    Do you have any of the following medical conditions or health-related issues?

    Medical Condition / Health Issue Medical Condition / Health Issue
    Pacemaker * Artificial Joint *
    Heart Failure * Heart Rhythm Disorder *
    High Blood Pressure * Heart Attack *
    Diabetes * Blood Thinners *
    Osteoporosis * Rheumatism *
    Glaucoma * Epilepsy *
    Asthma * Chronic Immune Deficiency *
    Hepatitis * Depression *
    Blood Clotting Disorder * Bulimia / Eating Disorder *
    Stroke * Bisphosphonate Use *
    Pregnancy? *
    Smoking? *
    Other Important Health Information

    Consents and Administrative Information*

    Appointment Cancellation / Missed Appointment Fee

    “Our practice operates on an appointment-only basis. If you are unable to attend your appointment, please cancel at least 24 hours in advance. A missed appointment fee will be charged for cancellations and missed appointments, regardless of the reason. We make every effort to fill any appointment slots that become available at short notice with patients from our waiting list. If we are successful, no missed appointment fee will, of course, be charged.”

    Download Offline Application Form of Children’s medical history form for printing
    Download PDF

      CHILDREN’S MEDICAL HISTORY FORM

      Dear Parents, a thorough medical history is essential for properly preparing for and providing subsequent treatment for your child at our practice. Please take your time to complete this form fully and carefully.

      Personal Information

      Why Are You Visiting Us?*

      General Information

      Question
      Is this your child’s first dental visit? *
      Has your child received dental treatment before? *
      Have there been any problems with local anaesthesia? *
      Are there any special considerations regarding your child’s interactions with doctors or medical treatments? *

      Oral Hygiene

      Fluoride Use:

      Sucking Habits*

      General Health

      Medical Condition
      Asthma *
      Allergies *
      Heart condition *
      Diabetes *
      Epilepsy *
      ADHD *
      Does your child take any medication? *
      If yes, please specify:

      Your Child’s World

      Consents and Administrative Information*

      Appointment Policy / Missed Appointment Fee

      Our practice operates on an appointment-only basis. If you are unable to attend an appointment, we kindly ask you to cancel at least 24 hours in advance. For appointments that are missed or cancelled at short notice, we reserve the right to charge a missed appointment fee in accordance with applicable legal requirements. *