New Patient Form

General Patient Information
Patient Name*

First NameLast Name
Preferred name
Patient Gender*
Patient Birth Date*

MonthDayYear
Marital Status*

SingleMarriedDivorcedChildOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Card #*
Cell Phone*
Home Phone
Parent/Guardian Name

First NameLast Name
Patient E-Mail
Preferred method of contact*

EmailTextPhone call
This contact is for*

MyselfEntire family
How did you hear about us?

Word of mouthFlyerNewspaperInternetEventLocationAn Apple Tree Patient
Name of person who referred you to us

First NameLast Name
Patient Medical History
Family Doctor*
Name / Phone Number
Please list any drug allergies*
Have you ever had (Please check all that apply)*

AIDSAllergies, SeasonalAsthmaArtificial JointsBlood DiseaseBruise easilyCancerDiabetesDizzinessEpilepsy SeizuresAutisticDown SyndromeExcessive BleedingFaintingGlaucomaGrowthsHay FeverHeart DiseaseHeart MurmurHepatitis (A, B or C)High Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerUlcerPregnancyRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismThyroid ProblemsTuberculosisSinus ProblemsStomach ProblemsStrokeLung DiseaseTumorsVenereal DiseaseSmokingNONE
Other illnesses:*
Please list your Current Medications*
Have you ever had any complications following a medical or dental procedure? If so please explain:*
If yes, please explain
Have you been admitted to a hospital or needed emergency care during the past two years? If so please explain: *
Are you now under the care of a physician for any specific health concerns? If yes please explain: *
Is there anything else you think we should know regarding your medical history? if yes please explain: *
Dental History
Date of last dental visit
Reason for today's visit
Please check any of the following that apply to you:*

Headaches, ear aches or neck painBad breath or bad taste in your mouthTeeth or fillings breakingJaw joint pain (clicking or cracking)Loose or shifting teethnone
If you could change your smile you would:*

Make your teeth whiterStraighten your teethClose spaces between your teethReplace dark metal fillings with tooth coloured fillingsReplace old crownsRepair chipped teethHave a complete smile makeovernone
Please circle any of the services below you would like our staff to discuss with you during your visit:*

Tooth bleaching/Zoom WhiteningTraditional orthodontics (braces)InvisalignVeneersHalitosis (bad breath)Smile makeoverNitrous / sleep DentistryPartials / denturesAnti-snore guardsSports guardsnone
Please thoroughly read and mark off all items:*

To the best of my knowledge, all of the information I have given today is true and correct. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes to my medical statusI authorize the release of the information contained in claims submitted electronically to my issuing company plan administrator and the Canadian Dental Association.I certify that I have insurance coverage and assign any insurance benefits from claims submitted electronically or by mail otherwise payable to me, directly to Dr. Timothy S Chai or to Apple Tree Dentistry for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.
Consent to Treatment *

I, the undersigned, consent to the diagnostic procedures and treatment by the dentist and staff of Apple Tree Dentistry necessary for proper dental care. I have read and understand the above conditions of treatment and payment and agree to their content.
Signature *

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General Patient Information

Patient Medical History

Dental History