Children's New Patient Form

	(250) 374-7227
	info@drmarnie.com Suite 402-275 Lansdowne St. Kamloops, BC, V2C 6J3 Toll Free: 1(877) 994-7227

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Dr Marnie Plant

Children's New Patient Form

Please fill out the following information below.

Name: *

Date of Birth: *

Gender * Male Female

Parents Name: *

Parents Date of Birth: *

Address: *

City: *

Province: *

Postal Code: *

Phone: (Home) *

Phone: (Work)

Phone: (Cell)

How did you hear <br>about Dr. Marnie?

Email: *

Medical History:

Please select any condition for which your child has been treated or has currently. Diabetes
Rheumatic Fever
Epilepsy
Heart Disease
Hepatitis or HIV
Prolonged Bleeding
Cold sores
Canker sores
Environmental Allergies
Local anesthetic sensitivity
Allergy to Medications
Asthma
Teeth Grinding
Snoring
Thumb Sucking
Speech Impediments
Dental Phobia
TMD or TMJ

Family Physician:

Have they had any serious past illnesses or surgeries: Yes No

Do they take any current medications including herbal medication: Yes No

Are they currently being treated for any conditions not listed? Yes No

We want to be here for you. If there were one thing we could do to help meet your needs what would that be?

Type the characters you see in the picture below

New Patient Experience
High Tech Dentistry
Cosmetic Smile Makeover
Sleep Dentistry / Sedation
Hygiene / Periodontal Disease
Removing Mercury Fillings
Zoom Whitening
Botox Cosmetic ®
TMJ / TMD Treatment
Lasers - No Needles
Neuromuscular Dentistry
Digital Xrays / Less Radiation

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