Metropointe Dental Patient Form Final

Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
SIN
Email
Person Financially Responsible and relation
Employer
Occupation
Previous Dentist
Family Doctor
EMERGENCY CONTACT
Emergency Contact Phone
Format: (000) 000-0000.
How did you hear about our office?
Dental Insurance
Do you have dental insurance?
Our Staff will gladly process your insurance forms to their best knowledge, but please DO NOT HOLD US RESPONSIBLE as your INSURANCE AGENT
Insurance Company #1
Group #
ID#
Dep#
Deductible Amount ($)
Annual Limit
Policy Holder's Name
Date of Birth (Policy Holder)

MonthDayYear
Date
SIN of Policy Holder
Policy Holder's Employer
Employer's Phone
Format: (000) 000-0000.
Insurance Company #2
Group #
ID#
Dep#
Insurance Coverage (%)
A. Coverage %
B. Coverage %
C. Coverage %
D. Coverage %
Deductible Amount ($)
Annual Limit
Policy Holder's Name
SIN of Policy Holder
Date of Birth (Policy Holder)

MonthDayYear
Date
Policy Holder's Employer
Employer Phone
Format: (000) 000-0000.
Medical History
Do you have a current medical problem?
If yes, what kind?
Are you taking any medication?
If yes, what kind?
Do you have high or low blood pressure?
Do you have pains in your chest?
Have you ever had any major operations?
If yes, what kind?
Have you ever been involved in a serious accident
If yes, what kind?
Do you bruise easily?
Do you smoke
If yes, how much?
Any drug allergies?
If yes, specify which drug(s)?
For FEMALE only, are you pregnant?
Please tell us any medical conditions that you have (e.g. Diabetes, Arthritis etc.)

Other diseases
Dental Background
How can I help you?
Childhood, regular dental care?
Last Visit
Reason
Problems you are aware of
Are conditions getting worse?
How many times do your brush daily?
Do you:
Do you have neck or shoulder pain?
If yes, how severe?
Have you ever had orthodontic treatment?
How long do you plan to keep your teeth?
Have you required a lot of dental work in the past?
Has anyone showed you how to clean your teeth properly?
Are you satisfied with the appearance of your teeth and your smile? If NO, please explain in the box below.

No
Are your teeth well-aligned (straight)? If NO, please explain in the box below.

No
Do you have some spaces between your teeth that you don't like? If YES, please explain in the box below.

Yes
Do you like the color of your teeth? If NO, please explain in the box below.

No
Do you like the shape of your teeth? If NO, please explain in the box below.

No
Do you like the way teeth come together? If NO, please explain in the box below.

No
Are your teeth:
What would you like to change the most in the appearance of your teeth?
Will you allow us to take your before and after dental treatment photos for educational and marketing purposes for the clinic. Please note: The photos will only show the dental treatment and not reveal your whole face.
Permit of Operation
This is to certify that I, undersigned, have disclosed true and complete information on this form. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general anesthetic or local anesthetic as indicated. In addition, I will assume responsibility for fees associated with the completed treatment.
Patient's (Parent's) signature
Date

MonthDayYear
Date
- Should be Empty:

Dental Insurance

Medical History

Dental Background

Permit of Operation