Patient Registration Form

Patient Registration Form

Thank you for choosing Rideau Dental on 4th Street for your Dental Care!
Patient Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Contact In Case of Emergency
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation*
For New Patients
How did you hear about us ?*
Last Dental Visit *

MonthDayYear
Date
Previous Dentist*
What concerns you most about your teeth? (Example: bad breath, decay, whitening)
Dental History
Please Check any of the following that applies to you *

Are you presently in dental pain?Do you feel nervous about having treatment?Have you ever had a bad experience in a dental office ?Have you ever experienced any unfavorable reactions to dentistry?Have your wisdom teeth been removed ?Have you ever had excessive bleeding requiring special treatment (after a tooth extraction)Have you ever lost or chipped any teeth?Have there been any injuries to your face,mouth or teethIs any part of your mouth sensitive to temperature or pressureDo your gums bleed when you brush/floss?Are you a mouth breather?Have you had orthodontic treatment (Braces/Invisalign)?Do your jaws or teeth ever feel uncomfortable when you wake up?Are you aware of your jaw clicking or popping?Have you ever been told you grind your teeth?Do you have "tension" headaches ?Have you ever experienced chronic ringing in your ears?None of the AboveOther
Please provide additional details if you checked any of the above: *
Medical History
Medical Alerts /Allergies (Example: allergy to penicillin)*
Current Medications/Recreational Drugs*
Physician's Name*
Date Of Last Visit

MonthDayYear
Date
Please check any of the following that applies to you*

Have you been a patient in a hospital during the past two years?Have you been under the care of a medical doctor during the past two years?Have you taken any medicine or drugs during the past two years?Have you or do you smoke or chew tobacco?Women : Are you pregnant ?None of the aboveOther
If you checked any of the above - please provide additional details: *
Please check any of the following which you have had or have at present*

Heart FailureHeart AttackStrokeHeart DiseaseAnginaHigh Blood PressureHeart MurmurRheumatic FeverCongenital Heart DefectsScarlet FeverArtificial Heart ValveHeart PacemakerHeart SurgeryArtificial JointAnemiaKidney TroubleUlcersBrain InjuryEmphysemaTuberculosisAsthmaHay FeverSinus TroubleAllergies/HivesDiabetesThyroid DiseaseTumor or CancerChemotherapy/RadiationArthritisRheumatismsGlaucomaHIV/AIDSHepatitis/Liver DiseaseYellow/JaundiceBlood TransfusionsDrug/alcohol addictionHemophilia/abnormal bleedingVenereal Disease ( Syphillis, Gonorrhea)Cold SoresEpilepsy or SeizuresFainting/DizzinessPsychiatric TratmentBruise EasilyNone of the AboveOther
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any changes in my health or if my medications change, I WILL INFORM THE DENTAL TEAM AT THE NEXT APPOINTMENT WITHOUT FAIL.
Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

Patient Registration Form

Patient Information

Contact In Case of Emergency

For New Patients

Dental History

Medical History