WELCOME TO OUR DENTAL OFFICE
The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.
Office use only
ID #
Medical Alert?
Yes
No
Date
-
Month
-
Day
Year
Date
REGISTRATION INFORMATION
This information will enable us to maintain communication with you.
This patient is an:
Adult
Child
Child under Guardian
Name of Guardian
Name
Prefix
First Name
initial
Last Name
Prefers to be called:
name preference
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Business Phone:
business phone
Format: (000) 000-0000.
Ext:
ext.
Employer
May we call you at work?:
Yes
No
Mobile Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date of Birth
Sex
Age
Age
Marital status
Spouse's Name
Preferred appointment time:
pref time
Whom may with thank for referring you?
referrer
. Are other family members patients at our office?
Yes
No.
Names:
other family members that are patients
MEDICAL PRIORITY
This information will enable us to make any essential contacts.
In case of emergency
Family Physician:
Physician name
Last Name
Physician: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Specialist:
First Name
Last Name
Specialist: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
In case of an emergency contact:
First Name
Last Name
Emergency contact phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Name of nearest relative not living with you
First Name
Last Name
Nearest Relative Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for today's visit?:
Examination
Emergency
Other
Other:
Is there a dental problem you would like treated immediately?
FINANCIAL INFORMATION
This information is necessary to process invoices and apply payments.
Person responsible for the account: (Please complete all information only if different from above)
Self
Spouse
Other
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employed by:
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Method of Payment
Cash
Cheque
Credit Card
Other
Enroll
Should be Empty: