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Call either of our locations today at
519-749-9981
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(519) 749-9981
5 Meadowcreek Ln
Cambridge
545 Parkside Dr
Waterloo
M-T: 7:30-5
F: 8-3
Welcome
Office
Info
Meet Our Doctors
About Smiletown
Office Tour
Financial & Insurance
In the Community/Partners
Parents
Info
New Patient Form
Why choose a children’s dental office?
First Visit
Autism Program
Special Needs Intake Form
Our Technology
Key Messages for Parents
FAQ
Treatment
Info
Consultation
Digital X-Rays
Fixing Baby Teeth
Sedation & Behaviour
Management
Types of Sedation and Anaesthesia
Sedation and Anaesthesia Safety
Referrals
Dentist Referrals
Refer a Friend
Contact
Employment Opportunities
Special Needs Dental Intake Form
Medical Information
Patients Name
*
Patients Age
Parent / Guardian
Telephone (m)
*
Email
*
Describe the nature of your child's disability
*
Does your child have any other physical challenges that the dental team should be aware of?If yes, please explain
Oral Care
Has your child visited the dentist before?
Yes
No
If yes, please describe
What are your dental health goals for your child?
Please describe your child's at-home dental care
Communication and Behaviour
Are there any symbols / signs that we can have available to assist with communication?
Are there certain cues that might help the dental team?
Is your child able to communicate verbally?
Yes
No
Does your child use non-verbal communication?
Yes
No
Please check any of the following that your child uses
Mayer Johnson Symbols
Sign Language
Picture Exchange Communication Sysytem ( PECS )
Sentence Board or Gestures
Will you be bringing a communication system with you?
Yes
No
Behaviour / Emotions
Please list any specific behaviour challenges that you would like the dental team to be aware of
Sensory Issues
Does your child prefer the quite?
Yes
No
Please list any specific sounds that your child is sensitive to
Is your child more comfortable in a dimly lit room
Yes
No
Is your child more comfortable in a clutter-free environment?
Yes
No
Is your child sensitive to motion and moving ( i.e. the dental chair moving up and down or in a reclining position )?
Yes
No
Please explain
Do certain tastes bother your child?
Yes
No
If yes,please list below
Does your child have any specific oral sensitivities ( gagging,gum,sensitivity,etc.)?
Yes
No
Please explain
Please provide us with any additional information that may help us to prepare for a successful dental experience
Preferred Location
*
Cambridge
Waterloo
CAPTCHA
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Key Messages for Parents
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Avoid the sweet temptation!
Never dip a pacifier into honey or anything sweet before giving it to a baby.
Read more
