Metropointe Dental Patient Form Final

Name*

First NameLast Name
Title*

Mr.Mrs.MissMstDr.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
SIN
Email*
Person Financially Responsible and relation
Employer
Occupation
Previous Dentist*
Family Doctor*
EMERGENCY CONTACT*
Emergency Contact Phone*
How did you hear about our office?
Dental Insurance
Do you have dental insurance?*

YesNo
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
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
Medical History
Do you have a current medical problem?*

yesNo
If yes, what kind?
Are you taking any medication?*

yesno
If yes, what kind?
Do you have high or low blood pressure?*

HighNormalLow
Do you have pains in your chest?

yesnooccasionally
Have you ever had any major operations?*

yesno
If yes, what kind?
Have you ever been involved in a serious accident*

yesno
If yes, what kind?
Do you bruise easily?*

yesno
Do you smoke*

yesno
If yes, how much?
Any drug allergies?*

yesno
If yes, specify which drug(s)?
For FEMALE only, are you pregnant?

yesno
Please tell us any medical conditions that you have (e.g. Diabetes, Arthritis etc.)

HepatitisSinusitisArthritisDiabetesEpilepsyAnemiaAsthmaARC/AIDS (HIV)Muscular dystrophyMultiple Sclerosis (MS)Psychiatric careThyroid diseaseImmune disordersTuberculosis/Lung diseaseBlood disordersVenereal diseaseHeart problem or strokeKidney/Liver diseaseGastrointestinal diseaseAbnormal blood pressureRheumatic fever or heart murmurArtificial joint or valvesRadiotherapy or chemotherapyMental or nervous diseaseOther diseases
Dental Background
How can I help you?*
Childhood, regular dental care?

YesNo
Last Visit
Reason
Problems you are aware of
Are conditions getting worse?
How many times do your brush daily?

123
Do you:

Floss?Use toothpick?Have any food traps?Have any bleeding gums?Have bad breath?Have any missing teeth?Have any replaced teeth?Have any teeth suggested for replacement?Have any stomach problems or indigestion?Grind or clench your teeth?Have any joint noises?Have chronic headaches?Have backaches?Have neck or shoulder pain?
Do you have neck or shoulder pain?*

yesno
If yes, how severe?
Have you ever had orthodontic treatment?

yesno
How long do you plan to keep your teeth?
Have you required a lot of dental work in the past?*

yesno
Has anyone showed you how to clean your teeth properly?*

yesno
Are you satisfied with the appearance of your teeth and your smile? If NO, please explain in the box below.

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

YesNo
Do you have some spaces between your teeth that you don't like? If YES, please explain in the box below.

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

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

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

YesNo
Are your teeth:

Chipped?Protruding?Hidden?
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.

yesno
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

Clear
Date

MonthDayYear
Date

Should be Empty:

Dental Insurance

Medical History

Dental Background

Permit of Operation