www.lcdcare.ca - New Patient Form

Your Name*

First NameLast Name

Date of Birth*

Date

Today’s date*

Date

Gender*

Your medical doctor’s name

First NameLast Name

Doctor’s Phone Number

Area CodePhone Number

Are you being treated by a medical doctor now?*

YesNo

If yes, for what?*

Have you ever been hospitalized or treated for a serious illness or injury?*

YesNo

If so, please explain*

Do you bleed easily or do cuts in your skin stay open a long time?*

YesNo

Have you ever fainted?*

YesNo

How long ago?*

Do you have any pains in the chest?*

YesNo

How long ago?*

Do you have or are you a carrier of an infectious disease?*

YesNo

If yes, which ones?*

Are you allergic (i.e. itching, swelling of hands, feet, or eyes) or made sick by any medicines? Penicillin or other antibiotics, Local anesthetics (freezing), Aspirin, Codeine, Sulfa,*

YesNoOther

If yes, which ones?*

Are you being treated for osteoporosis?*

YesNo

Please describe type of treatment

Are you taking any medicine or pills of any kind, including oral contraceptives, and herbal medicine?*

YesNo

Please list medications*

Do you have or ever had any of the following (please Check)

Are you pregnant?*

YesNo

When is the due date?

Date

Are you presently in good health?*

YesNo

Describe*

Is there anything else about your health that we should know about?*

YesNo

If so, what?*

Are you experiencing any of the following? (please Check)

Are your teeth sensitive to

What Is your present concern about your mouth or teeth?

Have you had any problems with previous dental treatment?*

YesNo

If so, what?*

When was your last dental visit?

What was done?

Have you ever had any injury, surgery or x-ray therapy to the face, head, neck, mouth or jaws?*

YesNo

Do you smoke or chew tobacco?*

YesNo

If yes, how often?*

Do you brush your teeth*

At least 2x daily1x dailySometimes

Do you floss your teeth*

DailySometimesNever

Are you concerned about the appearance of your teeth or your smile?*

YesNo

I am concerned about

To the best of my knowledge, all the preceding answers are true and correct.
If I ever have any change in my health, or if my medicine changes, I will inform the dental staff at the next appointment.
I consent to whatever dental procedures, anesthetics, and/or x-rays that are necessary for the treatment of my case.
I will assume responsibility for fees associated with those procedures. Fee payment is due at the time of service unless other prior arrangements have been made with Dr. Palka Sawhney Sharma.
I have read the “Dental Office Personal Information Consent Form” and do consent to the collection, use, and disclosure of my personal information for the purpose of optimizing my health care

New Patient Form

Confidential Personal Information

Dental Insurance Information