www.mountroyaldental.com - Patient Registration Information

Patient Registration Information
Patient Name*

TitleFirst NameMiddle NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Age
Gender / Title*
Marital Status
Home Address*

Street Address

Street Address Line 2

CityProv.

Postal Code, APT Number
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Preferred Method of Contact?*

HomeWorkCellEmail
Whom may we Thank for referring you to our office?
Employer Details
Employer
Occupation
Emergency Contact Details
His / Her Name*
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Doctor's Details
Doctor's Name
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party for Account
His / Her Name
Do You Have Dental Insurance?*

YesNo
Please give your information to the receptionist prior to your appointment.
Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
01. Have you ever been to hospital for any illnesses, operations, trauma/accidents, check-ups/tests?*

YesNo
If Yes, Please Explain*
02. Have you had a medical examination in the last year?*

YesNo
03. Are you currently under the care of a physician for any problem?*

YesNo
If Yes, Please Explain*
04. Are you presently taking any medicine, non-prescription drugs or herbal supplements?*

YesNo
If Yes, What and Why?*
05. Do you have, or have you ever had, any of the following?

Rhuematic FeverKidney DiseaseHeart TroubleDiabetesHeart MurmurLiver Disease (Jaundice, Hepatitis)Joint ReplacementHepatitis CAIDSMental or Nervous DiseaseSinusitisRadiation or X-ray TherapyStrokePacemakerStomach UlcersDrug / Alcohol DependencyOsteoporosis Medications (eg. Fosamax, Actonel)Thyroid DiseaseLung DiseaseHigh Blood PressureAsthmaVenereal DiseaseEpilepsyGastrointestinal DiseaseCancerBlood DisordersAnemiaChest pain, AnginaShortness of BreathSteroid TherapyDialysisNone of the above
If diabetes is selected, please select the type.*

Diabetes type 1Diabetes type 2
06. Do you have any conditions or therapies that could affect your immune system? (eg. Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

YesNo
07. Do you have any allergies?*

YesNo
If Yes, Please list using the categories below?
Medications (Penicillin, Sulpha, Aspirin, Codeine or Other)
Latex (Rubber Products)
Other (eg. Hay fever, food)
08. Have you ever had a peculiar or adverse reaction to any medications?*

YesNo
If Yes, Please Explain*
09. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (ie: infective endocarditis), a heart condition from birth (ie: congenital heart disease) or a heart transplant?*

YesNo
10. Do you have a bleeding problem or bleeding disorder?*

YesNo
11. Have you ever fainted?*

YesNo
If Yes, When?*
12. Are there any disease or medical problems that run in your family? (eg: diabetes, cancer, heart disease)*

YesNo
If Yes, Please Explain*
13. Do you smoke or chew tobacco products?*

YesNo
How Much?*
14. Are you aware of snoring?*

YesNo
15. Have you been diagnosed with sleep apnea?*

YesNo
Do you use a CPAP machine?*

YesNo
16. Is there anything that the dentist should know about your general health that has not been mentioned?*

YesNo
If Yes, Please Explain*
17. To the best of your knowledge, are you in good health?*

YesNo
Women Only
Are you pregnant / breastfeeding?*

YesNo
Are you on birth control pills?*

YesNo
Dental History
01. Last dental visit

MonthDayYear
Date
Reason
02. Last X-rays

MonthDayYear
Date
Reason
03. Are you aware of bad breath or a bad taste in your mouth?*

YesNo
04. Are you aware of grinding / clenching your teeth?*

YesNo
If Yes, Do you wear a night guard?*

YesNo
05. Do you have a history of jaw / TMJ problems?*

YesNo
06. Do you chew gum every day?*

YesNo
07. Have you ever had freezing (local anaesthetic) in your mouth?*

YesNo
Any ill effects from it?*

YesNo
08. Have you ever had a bad experience at the dentist?*

YesNo
09. What, if any, is your current dental problem?*
10. Are you nervous in the dental office? (Scale of 1 - 10, with 10 being Very Nervous)*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Office Policy
Please help us maintain the operation of our office on sound principles so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you. Therefore, 2 business days' NOTICE must be given if cancellation is absolutely necessary.

Office policy is that services are paid for at each visit as they are performed. However, in certain circumstances, arrangements for payment may be made by consulting the doctor prior to treatment.

Regarding insurance: All professional services are charged directly to the patient, and patients are personally responsible for payment of bills on their accounts. We will prepare any necessary forms or reports to help you collect your benefits from your insurance company.
Signature ( Patient, Parent / Guardian)*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Patient Registration Information

Employer Details

Emergency Contact Details

Medical Doctor's Details

Responsible Party for Account

Medical History

Women Only

Dental History

Office Policy