Personal InformationTitle*Mr.MrsMs.MissOtherFirst and last name* Date of Birth* DD slash MM slash YYYY Age*Gender*ChoiceMaleFemaleOtherAddress* City* Province* Postal Code* Email Address* Mobile PhoneHome PhoneWork PhoneHow did you hear about us? Preferred method of Contact*Mobile PhoneHome PhoneEmailSMSAdult Patient Yes No Child Patient Yes No Mother’s Name Mother’s Phone Father’s Name Father’s Phone Occupation Employer Name of Family Doctor Doctor's Phone In Case of Emergency, we should notifyName Relationship Phone Medical InformationAre you being treated for any medical condition at the present or have you been treated with the past year?(If Yes, please explain) Yes No Please explain When was your last medical checkup? Has there been any change in your general health in the past year?(If Yes, please explain) Yes No Please explain Are you taking any medications, non-prescription drugs or herbal supplements of any kind?(If Yes, please list medications and dosage) Yes No List medications and dosage Do you have any allergies?(If yes, please explain) Yes No Please explain Have you ever had a peculiar or adverse reaction to any medicines or injections?(If Yes, please explain) Yes No Please explain Do you have or have you ever had asthma?* Yes No Do you have or have you ever had any heart or blood pressure problems?* Yes No Do you have or have you ever had an artificial vales, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*(If Yes, please explain) Yes No Please explain Do you have a prosthetic or artificial joint?* Yes No Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Have you ever had hepatitis, jaundice or liver disease?* Yes No Do you have a bleeding problem or bleeding disorder?* Yes No Have you ever been hospitalized for any illness or operations?*(If Yes, please explain) Yes No Please explain Do you have or have you ever had any of the following?* No Chest pain, angina Shortness of breath Heart attack Rheumatic fever Mitral valve prolapes Heart murmur Pacemaker Lung disease Tuberculosis Stroke Steroid therapy Diabetes Stomach ulcers Arthritis Seizures (epilepsy) Kidney Disease Thyroid disease Cancer Osteoporosis Medications Drug/alcohol dependency Are there any conditions or diseases not listed above that you have or have had?*(If Yes, please explain) Yes No Please explain Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?* Yes No Do you smoke or chew tobacco products?* Yes No Are you nervous during dental treatment?* Yes No Women onlyAre you Pregnant?(If Yes, how many months?) Yes No How many months? Nursing? Yes No Taking Birth Control Pills? Yes No Dental InformationWhen was your last dental visit? Reason How often do you visit the dentist? How often do you brush your teeth? How often do you floss your teeth? Do any of the following cause tooth discomfort? Cold Hot Sweets Chewing Are you having any problems that require immediate attentions?*(If Yes, please explain) Yes No Please explain Do your gums bleed when you brush your teeth? Yes No Have you noticed an loose teeth? Yes No Do you clench or grind your teeth? Yes No If Yes, do you wear a Nightguard? Have you been diagnosed with sleep apnea? Yes No If Yes, do you wear a CPAP mask? Have you ever had orthodontic treatment (Braces or Invisalign?) Yes No Are you interested in straightening your teeth? Yes No Are you interested in whitening? Yes No Are you interested in crowns or implants? Yes No Have you ever had any complications or issues with previous dental treatment? Please list anything else not mentioned above regarding your past dental history. Insurance InformationInsurance Coverage Yes No Secondary Insurance (If Applicable) Yes No Policy Holder’s Name Second Policy Holder’s Name Policy Holder’s Date of Birth (DD/MM/YYYY): DD slash MM slash YYYY Second Policy Holder’s Date of Birth DD slash MM slash YYYY Your Insurance Company/Carrier Second Insurance Company/Carrier Group or Policy Number Second Group or Policy Number I.D./Certificate No. Second I.D./Certificate No. Employer Second Employer Cancellations & Missed AppointmentsYour appointment time has been reserved exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient. Appointments that are cancelled with less than 48 hours notice and missed appointments are subject to $50.00 fee. This fee will be due in full prior to your next scheduled appointment.General ReleaseI, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform all diagnostic procedures including and not limited to x-rays and photographs, as may be required to determine necessary treatment, and to perform necessary or advisable treatment. I understand that information provided form or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that my dental insurance may not cover entirely the total fee of services provided. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.First & Last Name* Email Address Draw your signature*
