Children’s Clinic Screening Registration Card

Fields denoted by an asterisk (*) are required

Child’s Name Child’s Name First Last
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Email Address
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Child’s Gender

Child’s Gender M F NS
Child’s Birthdate Child’s Birthdate / MM / DD YYYY
Appointment Information
Has the child ever applied to become or have you ever been a patient of U.W.O. Schulich Dentistry before?

Has the child ever applied to become or have you ever been a patient of U.W.O. Schulich Dentistry before? Yes No
Please indicate the year: (e.g. 2004)
Were you referred by your Dentist?

Were you referred by your Dentist? Yes No
Dentist's Name:
Referring Dentist's Phone Referring Dentist's Phone - ### - ### ####
for the treatment of
Date of last dental appointment Date of last dental appointment / MM / DD YYYY