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East Coast Pediatric Dentistry
Your Moncton Specialist
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Today's date
Patient's Name
Child's age
Date of Birth
Parent/Guardian
Telephone Number
Address
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Please select one (if this is applicable to your patient)
Dental Insurance
Indian Affairs
Social Assistance
Not Applicable
Type of treatment :
Extraction(s)
Restorative
Trauma
Root Canal Therapy
Treatment with Nitrous Oxide
Treatment with Sedation*
Treatment under General Anesthesia*
Transfer of Care
Medical history:
Healthy
Medically Complex
Behaviour Challenges
If medically complex, please provide details:
Does the Patient require SBE prophylaxis?
Yes
No
Has the child failed treatment attempts
Yes
No
Failed treatment type
With Local Anaesthesia only
With Local Anaesthesia and Nitrous Oxide
Date of last attempt:
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Adult Teeth Charting
Adult Teeth Chart
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Youth Teeth Charting:
Youth Teeth Chart
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X-Rays request :
X-Ray Included
X-Ray Emailed
Please Take X-Ray
X-Ray
You can upload multiple files by holding Ctrl (Windows) or Command (Mac) and clicking the desired file or files.
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Referring dentist:
Office email:
Remarks about treatment to be completed:
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