Peak Dental Arts - New Patients Form

Personal Information
Name

First NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
MaleFemaleI prefer not to say
Email
example@example.com
YESNO
Phone Number

Area CodePhone Number
Alternate

Area CodePhone Number
PhoneEmailText/SMS
FriendWalk ByGoogleYelpFacebook
Who may we thank for referring you?
Insurance
Insured Persons Name

First NameLast Name
Insured Birthdate

MonthDayYear
Date
Insurance Carrier
Employer
Policy/Group #
Insured ID/Certificate #
YESNO
Dental History
Name of Previous Dentist

First NameLast Name
When was your last dental visit?
When did you last have dental x-rays?
1x day2x day3x dayOther
ManualElectric
How often you floss your teeth?
List any other oral hygiene measures you use: (e.g. rinses, waterpik)
If yes, then please specify it on the field above.
NoYes
If so where?
NoYes
If so where?
NoYes
NoYes
If so where?
NoYes
NoYes
NoYes
NoYes
NoYes
Please list any concerns you may have
Medical History

The following information is required to enable us to provide you with the best possible dental care.All information is strictly private. We will review the questions and explain any you do notunderstand. Please fill in the entire form.
Name of Physician

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Drug Allergies
Are you taking any medications, non-prescriptive drugs or herbal supplements of any kind? Please list
YesNo
Please specify
List any medical conditions you are being treated for
AidsAsthmaArthritisAutoimmune DisorderBlood disorderCancerDiabetesEpilepsyHeart ProblemsHerpesHepatitisHigh Blood PressureHIVJaundiceLeukemiaLiver DiseaseLung DiseaseKidney DiseasePacemakerOsteoporosisStrokeTuberculosisThyroid DiseaseUlcersOther
YesNo
If so, how many per day or week?
YesNo
Due Date

MêsDiaAno
Consent to treatment and office policy
I authorize the doctor upon consultation and direct consent from the patient/parent/guardian to perform diagnostic procedures, treatment, x-rays and medication in the connection with the patient’s dental needs.I understand that the responsibility for payment of dental services, including insurance or otherwise, is due and payable at the time of services rendered and despite any dental insurance I am ultimately responsible for any fees withheld by the insurance company.I understand that I must provide 48 business hours to cancel or reschedule my appointments to avoid any fees.To the best of my knowledge all of the preceding answers are true and correct. If there are any changes I will without fail inform the Peak Dental Arts at my next appointment.I confirm I am the Patient or Parent or Guardian of the person listed in the form
To the best of my knowledge all of the preceding answers are true and correct. If there are any changes I will without fail inform the Peak Dental Arts at my next appointment.
Signed Date

MonthDayYear
Date
Please confirm that you are human.*
101 - 1312 Marine Drive , North Vancouver, B.C. V7P 1T4 P: 604-980-9999

info@peakdentalarts.com

http://www.peakdentalarts.com/
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Personal Information

Insurance

Dental History

Medical History

Consent to treatment and office policy