PDF Form

Please complete the following questionnaire as proper treatment requires that we become acquainted with each patients vital information. All questions answered within are strictly confidential. Please feel free to contact reception for clarification or help.

PERSONAL HISTORY

Name*

First NameLast Name

Preferred Name

Date of Birth*

MonthDayYear

Gender

MaleFemaleOther

Email*

example@example.com

Alt Phone Number

Preferred Phone Number*

Preferred Contact Method*

Address*

Street Address

Street Address Line 2

City

Postal Code

Emergency Contact*

First NameLast Name

Emergency Contact Phone*

Relation to Emergency Contact*

Whom may we thank for referring you?

Employer

Occupation*

DENTAL INSURANCE & DENTAL SERVICE PAYMENT

Patient’s payment will be due in full at the time treatment is rendered. We will assist patients submitting from their insurance. Please be aware that our fees may be higher than your dental plan may reimburse. If you have any questions or concerns regarding insurance please contact our office.

DENTAL INSURANCE

Primary Dental Insurance Carrier

Group/Policy Number

ID/Certificate Number

Name of Insured

Date of Birth of Insured

Plan Type

Eg. Student, Spousal, Retirement

Secondary Dental Insurance Carrier

Group/Policy Number

ID/Certificate Number

Name of Insured

Date of Birth of Insured

Plan Type

Eg. Student, Spousal, Retirement

DENTAL HISTORY

Former Dentist*

Phone Number

Date of last dental visit*

How often do you brush your teeth? *

How often do you floss?*

Do you use a rinse?

YesNo

Do your gums bleed?

YesNo

Do you have any dental concerns at present?*

MEDICAL HISTORY

Physician's Name*

Physicians Phone Number

Do you have any allergies?*

Have you been examined or treated by a physician recently?

YesNo

What medications or non prescription drugs are you taking now and what are they treating?*

Do you require antibiotic coverage prior to dental treatment? If Yes - please provide further details below*

YesNo

Do you have any of the following?

Women Only: Are you Pregnant? How many months?

Taking Oral Contraceptives

YesNo

Do you have any other health concerns the doctor should know about?

If applicable, Please provide details regarding antibiotic coverage requirements prior to dental work above*

We require a minimum of 2 business days notice to make any changes to your appointment. Please note we are closed weekends and statutory holidays. Your appointment time is reserved especially for you and a fee for short cancellations and missed appointments will apply.*

I understand and agree to the appointment policy

I consent to photography for record keeping.*

I understand and agree