Family Information
Todays Date

Year Month Day
Date
Child's Full Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Parent Name *

First Name Last Name
Parent's Email *
[email protected]
Mobile Phone Number *
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Name of Referring Practice *
Email of Referring Practice *
[email protected]

X-rays

(email digital records to [email protected])
Has the child had a Hygiene appointment? *

Yes No
Would you like to return patient?

Please return patient to referring office for recare.
BWs

Day Month Year
Date
PAN

Day Month Year
Date
PAs

Day Month Year
Date
Was treatment completed after x-rays were taken? *

Yes No
Please provide details.
File Upload

Cancel of

Referral Information
Reasons for Referral
Caries
Trauma
Behaviour
Other
Why is my child being referred to BabyTooth?
Dr. Kari is specialist which means she has 2 years additional training after dental school to gain the designation of pediatric dentist. The biggest component of pediatric dentistry is getting kids to cooperate for something they don’t want to do. Dr. Kari has ways of helping your child to cooperate ranging from behaviour management techniques, sedation, or even general anesthetic.
What can I expect at my child’s first appointment?
We need to get to know each other at this first visit. We do not want to overwhelm your child. Our goal is to make this first visit as easy as possible, to provide a caring and nurturing environment, and establish trust, as well as assess your child’s co-operation for future appointments. This means waiting until the second visit to perform dental work. At the end of the first visit, we will put together a treatment plan and review which options are right for your child. We can also provide a clear estimate of the cost and take the time to answer any questions you may have regarding treatment needs, cost and insurance. We ask that the child’s parent or legal guardian accompany the patient to the first visit. Please remember to bring your child’s Alberta Health Care card and all insurance information.
How soon can we get in for an appointment?
We need to get to know each other at this first visit. We do not want to overwhelm your child. Our goal is to make this first visit as easy as possible, to provide a caring and nurturing environment, and establish trust, as well as assess your child’s co-operation for future appointments. This means waiting until the second visit to perform dental work. At the end of the first visit, we will put together a treatment plan and review which options are right for your child. We can also provide a clear estimate of the cost and take the time to answer any questions you may have regarding treatment needs, cost and insurance. We ask that the child’s parent or legal guardian accompany the patient to the first visit. Please remember to bring your child’s Alberta Health Care card and all insurance information.
What should I do if my child is in pain?
Your child’s general dentist can prescribe antibiotics for an abscessed tooth or do a temporary filling for a deep cavity. Once your child has come in for their first appointment, we will take care of any pain or emergencies that might occur.
What should I do if my child is being referred for trauma?
Have your dentist call us ASAP. If it is after-hours, your dentist will determine if it is necessary to call Dr. Kari’s mobile number for her to come in for an emergency appointment.
Should be Empty:

Family Information

X-rays