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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
*If referring a patient for sedation or general anesthesia, please ensure the patient has a recent health physical completed (within 12 months) by their family physician or pediatrician and ask the family bring a copy with them to their consultation or have it faxed to 506-855-1919.
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
With Local Anaesthesia only
With Local Anaesthesia and Nitrous Oxide
Date of last attempt:
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Adult Teeth Charting
18
17
16
15
14
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12
11
21
22
23
24
25
26
27
28
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Youth Teeth Charting:
55
54
53
52
51
61
62
63
64
65
85
84
83
82
81
71
72
73
74
75
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X-Rays request :
X-Ray Included
X-Ray Emailed
Please Take X-Ray
X-Ray
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Referring dentist:
Office email:
Remarks about treatment to be completed:
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