New Patient Form

General Patient Information
Patient Name

First NameLast Name
Preferred name
Patient Gender
Patient Birth Date

MonthDayYear
Marital Status
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
This contact is for
How did you hear about us?
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)
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:
If you could change your smile you would:
Please circle any of the services below you would like our staff to discuss with you during your visit:
Please thoroughly read and mark off all items:
Consent to Treatment
Signature
Should be Empty:

General Patient Information