Teen's Information

The following information is required by West Grande Prairie Dental to assist in proper diagnosis and treatment. Please feel free to ask our receptionist for help completing this form.

Parent Information

Info of person responsible for payment of account.

Medical History

Specific History

Has your Teen been treated for any of the following:

Does your Teen have any of the following:

Dental History


As the parent and/or legal guardian of the patient, I do hereby request and authorize the dentists and staff to examine, clean, and provide dental treatment on my Teen. I further request and authorize the taking of dental x-rays as may be considered necessary to diagnose and/or treat my Teen’s dental problem. I will allow photographs to be taken of my Teen or Teen’s teeth for diagnostic or educational purposes. I understand that dental treatment for teens includes efforts to guide their behaviour by helping them understand the treatment in terms appropriate for their age. The dentists and staff will provide an environment that will help your Teen learn to cooperate during treatment including praise, explanations, and demonstrations of procedures and instruments. The usual and most frequent risks or complications occurring from dental operative treatment include but are not limited to, the possibility of pain or discomfort during the treatment, swelling, infection, bleeding and allergic reactions.

I understand I will be responsible for any charges incurred for my Teen for dental treatment. I affirm that the information above is correct to the best of my knowledge. I understand it is my responsibility to inform West GP Dental of any changes in my Teen’s medical status.

We require 48 hours notice to move or cancel an appointment. If you are unable to provide this to our office more than once, we will then require a deposit be placed prior to booking. If the appointment is cancelled again without sufficient notice the deposit will be used as compensation for our time. Please sign that you have read and understand our policy.