Patient Medical and Dental History

Patient Medical History

Name*

Patient's First NamePatient's Last Name

Nickname

Date of Birth*

Date

Gender*

Referred by (e.g. Google, Facebook, Friend)*

Address*

Address

Street Address Line 2

City, Province and Postal Code

Emergency Contact's Name*

Emergency Contact's Phone Number*

Is the patient the primary insurance policy holder?*

I am not covered under a dental insurance planYesNo

Policy Holders Full Name

First NameLast Name

Date of Birth

Date

Policy Holders Employer

Insurance Carrier

ID/ Member #

Group #

Is the patient the secondary insurance policy holder?*

I am not covered under a second dental insurance planYesNo

Policy Holders Full Name

First NameLast Name

Date of Birth

Date

Policy Holders Employer

Insurance Carrier

ID/ Member #

Group #

What is your estimate of your general health?

ExcellentGoodFairPoor

Hospitalization for illness or injury

YesNo

If yes, please explain:

Do you have allergies to any of the following:*

If other, please explain:

Medical *

	Yes _____	No _____	Please Explain ______________________________________________
Have you ever had joint replacement surgery
High or low blood pressure
Stroke
Anemia or other blood disorders
Prolonged bleeding due to a slight cut (or INR > 3.5)
Pneumonia, emphysema, shortness of breath
Chronic ear infections, tuberculosis, measles, chicken pox
Breathing problems (e.g. asthma, stuffy nose, sinus congestion)
Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
Kidney disease
Liver disease or jaundice
Thyroid, parathyroid disease, or calcium deficiency
High cholesterol
Diabetes
Stomach or duodenal ulcer
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
Arthritis or gout
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Head or neck injuries
Epilepsy, convulsions (seizures)
Viral infections and cold sores
Do you currently have or had a history of any heart conditions (e.g. cardiac stent, infective endocarditis, heart attack, artificial valve, pacemaker)?
STI/STD/HPV
Hepatitis
HIV/AIDS
Tumor, abnormal growth
Radiation therapy or Chemotherapy
Psychiatric treatment
Concentration problems or ADD/ADHD diagnosis
Alcohol/recreational drug use
Vertigo (e.g. ”the room is spinning”)
Hives, skin rash, hay fever

Presently being treated for any other illness*

YesNo

Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)*

YesNo

Taking dietary supplements*

YesNo

Often exhausted or fatigued*

YesNo

Experiencing frequent headaches or chronic pain*

YesNo

A smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)*

YesNo

Considered a touchy/sensitive person*

YesNo

Taking birth control pills*

YesNo

Currently pregnant*

YesNo

Diagnosed with a prostate disorder*

YesNo

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List below all medications or supplements taken within the last two years and their purpose:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

Cancellation Policy: At Newbury Dental, we pride ourselves in offering outstanding customer service. This includes providing a team of highly qualified health care professionals and an efficient delivery of care. In return, we appreciate a commitment from clients to be responsible for attending their appointments. Patients who fail to show for their appointments or who cancel without 48 hours notice will be subject to a $75 fee for missing up to one hour of reserved time and an increased amount for missing longer appointments.

*As with certain office policies, there will inevitably be exceptions that will be dealt with on a case-by-case basis.

Our commitment at Newbury Dental is to provide our patients with exceptional care and service. We thank you for your time and cooperation!

Photography Consent: Newbury Dental may take photographs and/or videos of your teeth and jaws, before, during, and after completion of any dental treatments. These photos and/or videos may be used for dental records, communication with other health professionals, research, education, patient counselling and marketing material. Written consent will not be obtained if the photographs and/or videos are used anonymously, and will only be required if your name or other identifying information will be revealed.

I have thoroughly read and understand the questions above. I certify that I have provided an accurate and complete medical history.

Name*

First NameLast Name

Guardians Name (for patients under the age of 18)

Guardians First NameGuardians Last Name

Signature*

Today's Date*

Date

Policy Holders Primary Insurance Information

Policy Holders Secondary Insurance Information

DO YOU HAVE or HAVE YOU EVER HAD:

ARE YOU:

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Dental History

PLEASE ANSWER TO THE FOLLOWING:

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS