New Minor Patient Form with Anaesthetic Consent 2026

PATIENT INFORMATION (MINOR)
- Title
- First Name*
- Middle Initial*
- Last Name*
- Preferred Name*
- Date of Birth*
  yyyy/mm/dd
- Care Card Number*
- Gender
  - Male
  - Female
  - Other
- Mailing Address*
- Physical Address*
- City*
- Province*
- Postal Code*
- Country*
- Home Phone
- Cellular Phone*
- School*
- Email*
PARENT/GUARDIAN INFORMATION
- Mother*
- Phone*
- Date of Birth*
- Email*
- Father*
- Phone*
- Date of Birth*
- Email*
- Guardian
- Phone
- Date of Birth
- Email
IN CASE OF EMERGENCY
Please specify who we should notify
- Name*
- Contact Phone*
- Relationship*
GENERAL CONSENT
I am the parent, guardian, or personal representative and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental team at MacKenzie Dental Centre to perform the necessary dental services for the child/minor named above, including but not limited to X-rays and administration of anesthetics, which are deemed advisable by Dr. Philomena Gale and/or Associate(s), whether or not I am present when the treatment is rendered. Terms and Conditions *
*
I agree*
- Parent/Guardian Signature*
- Date*
- Parent/Guardian Name*
Dental History
- Reason for your visit*
- Former Dentist*
- Email*
- City & Province*
- Phone*
- Date of last dental visit*
- Date of last dental radiographs*
Has minor/child complained about dental problems?*
- Yes
- No
Does minor/child brush twice daily?*
- Yes
- No
Does minor/child use floss daily?*
- Yes
- No
Is fluoride taken in any form?*
- Yes
- No
Have there been any unhappy dental experiences?*
- Yes
- No
Have there been any injuries to the mouth, teeth or head?*
- Yes
- No
Are there any mouth habits, e.g., thumb sucking, nail biting, etc?*
- Yes
- No
MEDICAL HISTORY
- Family Doctor*
- Address*
- Phone*
- Reason for visit*
- Date of last visit*
Please check the box if the minor/child has any history of or difficulty with any of the following:
Please check the box if the minor/child has any history of or difficulty with any of the following:
- Heart problems
- Heart murmur
- Congenital heart defect
- Rheumatic fever
- Artificial joints
- Digestion problems
- Special diet
- Sinus trouble
- Asthmas
- Breathing difficulties
- Tuberculosis (TB)
- Tobacco use
- E-Cigarettes use
- Chemical dependency
- Cannabis use
- Alcohol dependency
- Blood transfusion
- Anemia
- Blood disorder
Blood disorder type
Blood disorder type
Please check the box
- Headaches
- Anxiety
- Diabetes
- Thyroid disease
Please check the box
- Cortisone treatments
- Venereal disease
- HIV/AIDS
- Skin rash
- Allergies/Hives
- Weight loss
- Epilepsy
- Seizures
- Fainting or dizzy spells
- Use of contact lenses
- Liver disease
- Hepatitis
Hepatitis type
Hepatitis type
Please check the box
- Jaundice
- Kidney disease
- Bladder problems
- Cancer
- Chemotherapy
- Radiation therapy
Has the minor/child ever experienced any reactions to dental or general anesthesia? If yes, please describe.*
Have you ever been advised that the child needs to take antibiotics before dental appointments?*
Please list any medications, supplements or vitamins that the minor/child is currently taking or is supposed to be taking.*
Please list any allergies or reactions to any medications or to Latex.*
Has the minor/child ever had an operation or been hospitalized? Please detail the circumstances and any complications.*
To the best of my knowledge, the information provided is complete and correct. I understand that it is my responsibility to inform Dr. Philomena Gale and/or Associate(s) if my minor/child ever has a change in health.*
yes
I have read the terms and conditions, cancellation policy, payment policy, and personal information policy, and I understand my responsibilities as a patient.*
yes
- Parent/Guardian Signature*
- Date*
- Parent/Guardian Name*
Insurance Information
Do you have dental insurance coverage for the child?*
- Yes
- No
If coverage is on the same plan as the parent/guardian, please specify dependant number
If Insurance coverage is different, please complete the following:
- Subscriber
- Insurance Co.
- Relationship to Patient/Child
- Group/Policy#
- Subscriber’s Date of Birth
- ID/Cert. #
- Subscriber’s Employer
- Notes
- Subscriber
- Insurance Co.
- Relationship to Patient/Child
- Group/Policy#
- Subscriber’s Date of Birth
- ID/Cert. #
- Subscriber’s Employer
- Notes
- INSURANCE ASSIGNMENT AND RELEASE I certify that my dependent has dental insurance with the above named Company(ies) and assign directly to Dr. Philomena Gale Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. It is my responsibility to notify the dental office of any insurance coverage changes. I authorize the use of my signature on all insurance submissions. Dr. Philomena Gale Inc. may use my minor/child’s health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the minor/child ceases to be a patient of this dental practice. Terms and Conditions*
*
- I agree
- Parent/Guardian Signature
- Date
- Parent/Guardian Name
INFORMED CONSENT: ADMINISTRATION OF LOCAL ANAESTHETICS
- There are potential complications inherent to the administration of local anaesthetics:
  (i) There may be an allergic reaction to the anaesthetic.
  (ii) There may be adverse medication reaction to the anaesthetic.
  (iii) There may be temporary or permanent injury to nerves and/or blood vessels from the injection.
  (iv) There may be inadvertent contact or penetration of a blood vessel resulting in a transient sensation of a racing heart rate and/or a warm sensation across part of the face. A hematoma or bruise may result, which will resolve on its own.
  (v) The injection areas may be uncomfortable following treatment.
  (vi) The jaw may be sore, stiff and/or have limited range of opening. Existing jaw joint issues may be aggravated.
  
  INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of local anaesthesia and have received answers to my satisfaction. I voluntarily assume any and all possible risks.
  
  By signing this form, I am freely giving my consent to allow and authorize the dentists and hygienist at MacKenzie Dental Centre to administer local anaesthesia as needed for my dental treatment.
- Name of Patient*
- Name of Person Responsible*
- Signature*
- Date*

PATIENT INFORMATION (MINOR)

PARENT/GUARDIAN INFORMATION

IN CASE OF EMERGENCY

GENERAL CONSENT

Dental History

MEDICAL HISTORY

Insurance Information

INFORMED CONSENT: ADMINISTRATION OF LOCAL ANAESTHETICS

There are potential complications inherent to the administration of local anaesthetics: