Patient Form

Today’s Date:*

Name*

First Name: Middle Initial: Last Name:

Date of Birth (D/M/YR):

Age

Address:

City:

Province:

Postal Code:

Home Phone:

Business Phone:

Cell Phone:*

Email Address:*

Care Card#

Name of Physician and date of last exam:

Pharmacy:

Emergency Contact:

Phone Number:

CIRCLE WHICH REMINDER TYPE YOU WOULD PREFER: (you may select more than one)

TEXT MESSAGE
EMAIL
PHONE CALL (which number)

PHONE CALL (which number)

How did you hear about us?

Referral? If yes, please let us know who so we may thank them

Business Referral? If yes, please let us know so we may thank them

Other? Please specify:

Do you have dental insurance?

Yes
No

Carrier:

Group/Plan #:

ID#:

Your Employer:

Your Occupation:

2 nd Carrier:

Group/Plan #:

ID#:

Employer:

Please complete if you are a NEW CLIENT:

Date of last dental visit:

Reason for visit:

Dental Office or Dentist, Location

Are you presently in pain?

Yes
No

What is your immediate concern?

Are your teeth sensitive to:

A) HOT/COLD

Yes
No

B) Sweets

Yes
No

C) Pressure

Yes
No

Have you had gum surgery?

Yes
No

Do your gums bleed when brushing?.

Yes
No

Do you have any pain or stiffness in your jaw, neck or face?

Yes
No

Do you wear dentures?

Yes
No

If so, please specify:

partial upper
partial lower
complete upper
complete lower

Have you ever had a reaction to local anesthetic:

Yes
No

Have you ever been told you grind your teeth while sleeping?

Yes
No

Do you avoid chewing with any part of your mouth?

Yes
No

Remainder to be completed by NEW CLIENTS and RETURNING CLIENTS:

Do you have any health concerns?.

Yes
No

Please Specify

Are you allergic or had a reaction to any medications?

Yes
No

If so, please specify:

Are you presently taking any medication (including oral contraceptives?)

Yes
No

Name of Drug & what for:

Do you use recreational drugs/alcohol?

Yes
No

How often

To the best of your knowledge, have you or are you afflicted by:

Heart Problems, Cardiac Stent or Cardiac Arrest in the last 6 months?

Yes
No

Heart Disease

Yes
No

Heart Murmur, Rheumatic Fever Or Scarlet Fever

Yes
No

High or Low Blood Pressure

Yes
No

Stroke

Yes
No

Diabetes

Yes
No

High Cholesterol

Yes
No

Kidney Disease?

Yes
No

Hepatitis, Type A, B, or C

Yes
No

Hearing Impairment

Yes
No

Diabetes

Yes
No

Epilepsy

Yes
No

HIV – AIDS

Yes
No

Prolonged Bleeding

Yes
No

Liver Problems

Yes
No

Ulcers

Yes
No

Epilepsy

Yes
No

Thyroid Problems

Yes
No

Radiation or Chemo Therapy

Yes
No

Osteoporosis or/and Taking Bisphosphonates?

Yes
No

Anemia or Other Blood Disorders

Yes
No

Asthma

Yes
No

Lung Disease

Yes
No

Digestive or Eating Disorders?

Yes
No

Gastric Reflux?

Yes
No

Arthritis

Yes
No

Artificial Joints, Pacemakers or Artificial Valves

Yes
No

Do you faint easily?

Yes
No

Any type of allergies? (Latex, Hay Fever…)

Yes
No

Please Specify

Auto-Immune Disease (Lupus, Rheumatoid Arthritis)

Yes
No

Women – are you pregnant (or think you may be pregnant)?

Yes
No

Do you snore loudly? (Louder than talking/loud enough to be heard through a closed door?)

Yes
No

Do you often feel tired, fatigued, or sleepy during the day?

Yes
No

Has anyone observed you stop breathing during your sleep?

Yes
No

Smoker or use other smoking/tobacco products

Yes
No

On a scale of 1 – 10, how would you rate your teeth, smile (1 being poor and 10 being perfect)

If you could change anything about your teeth/smile, what would it be?

Anything else you would like to inform us of:

Certification of Patient Understanding and Authorization

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. Privacy of our patient’s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft, and unauthorized access. Your personal information shall be disclosed to only those who have a need to know and specific information disclosed shall be restricted to only that information relevant to what the recipients need to know. Those who have a need to know include referring dentists, other dentist specialists, physicians, dental laboratories, and dental insurance companies. I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. In addition, I understand that any cancellation of appointments must be done two business days previous to the appointment or a late cancellation fee of $50 may be applied to my account (with the exception of certain extraneous circumstances). I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any). I hereby certify that I have read and understand the previous information and that the information I have provided is true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. I will keep the dental office updated with any changes to my health and/or medications and allergies. I also consent to email and/or text message reminders for future appointments.

SIGNATURE OF PATIENT/PARENT/GUARDIAN*

DATE SIGNED

RELATIONSHIP TO PATIENT (IF APPLICABLE)

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