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Contact: (289) 475 1011

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Child New Patient Registration Form

This field is for validation purposes and should be left unchanged.

Patient Information

Gender

Insurance Information of Parent/Guardian

Secondary Insurance

If the child has secondary coverage:

Medical History

Are you currently under medical treatment?

Allergies

Have you had an allergic or unusual reaction to any of the following? Leave blank if all answers are No.
Aspirin
Codeine
Dental Anesthetic
Penicillin

Medical Conditions

Have you ever been treated for any of the following? Leave blank if all answers are No.
Anemia
Asthma
Diabetes
Emphysema
Epilepsy
Glaucoma
Hay Fever
Heart Murmurs
Hepatitis
Sinus Trouble
Stroke
Jaundice
Kidney Disease
Rheumatic Fever
Tuberculosis
Ulcers
Venereal Disease

Additional Medical Questions

Please answer all questions below:
Have you ever been treated for AIDS-related complex?
Are you taking any medications? If so, what are they?
Are you currently taking Ozempic or any other GLP-1 receptor agonist medication (such as Wegovy, Mounjaro, Rybelsus, Saxenda, etc.)?
Do you have heart trouble? If so, what kind?
Do you have high or low blood pressure? Is it controlled?
Have you ever been required to take prophylactic antibiotics prior to dental treatment?
Do you use tobacco products? If so, how often?
Are you subject to fainting or dizziness? If so, how often?
Have you ever had cancer or a tumor? If so, how was it treated?
Have you ever had any major operations? If so, what kind?
Have you ever been diagnosed with, or been told you may have, sleep apnea or another sleep-related breathing disorder? If yes, please provide details, including whether you use CPAP/BiPAP or another treatment.
Have you ever had sedation or general anesthesia before? If yes, did you experience any problems, complications, or unusual reactions?
Do you have any current or previous history of drug or substance abuse, misuse, or dependence, including recreational or illicit drug use? If yes, please provide details.
Have you ever been involved in a serious accident?
Do you bruise or bleed easily?
Have you recently had a communicable disease (i.e. Mumps, Measles, etc.)?

Dental History

Are you presently in any dental pain?
Is any part of your mouth sensitive to temperature, pressure or sweets?
Do you have an unpleasant taste or odor in your mouth?
Have you ever gotten food stuck between your teeth?
Do you awaken with pain in your teeth or jaws?
Do you have frequent headaches or facial pain?
Are you aware of jaw clicking or popping while eating or yawning?
Do you ever get cold sores or fever blisters?

Office Policy

We will gladly complete Dental Insurance Claim Forms with the following understanding:

  1. The patient is financially responsible for the entire cost of the treatment.
  2. Payment is to be made to “Oris Dental Clinics” by the patient or by direct billing to the insurance company.

iTrans

Benefits payable from claims submitted electronically will be assigned to Oris Dental Clinics and payment will be received by the Dentist directly.

CANCELLATION / NO SHOW POLICY

At least 48 hours notice is required if you must cancel/reschedule your appointment for any reason.

Missed Appointments will incur a firm charge of $100.

All outstanding fees must be paid in full before further appointments will be booked.

Should you miss an appointment, it is your responsibility to call and rebook.

Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.

Statement of Understanding

I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Oris Dental Clinics' policy and understand that breaching it in anyway may result in disciplinary action.

Write any messages or additional information in here.
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EXCITING NEWS FROM ORIS DENTAL CLINICS!

We’re excited to announce that Orthodontics is now available at Oris! Please join us in welcoming Dr. Arash Poursattar Bejehmir, Orthodontist, who will be joining our team beginning September 10, 2026.
Whether you’re considering orthodontic treatment for your child, your teen, or yourself, we’re happy to make your care even more convenient — right here at Oris Dental Clinics.

Orthodontic consultations are available for:
• Crowded or crooked teeth
• Gaps and spacing
• Overbites, underbites and other bite concerns
• Braces, clear aligners, and orthodontic treatment options
• Children, teens and adults

Back-to-school is the perfect time to start thinking about a healthier, more confident smile!
Appointments are now being booked for September 10th.

Contact our office today to reserve your Orthodontic Consultation.

Click here

Oris Dental Clinics
Your smile. Our specialists. All in one place.