Metropointe Dental Patient Form

Name

First Name Last Name
Title

Mr. Mrs. Miss Mst Dr.
Address

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
SIN
Email
Visa/MC #
Expiry Date
Type in MM/YY
Care card #
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
Our Staff will gladly process your insurance forms to their best knowledge, but please DO NOT HOLD US RESPONSIBLE as your INSURANCE AGENT
Do you have dental insurance?

Yes No
Insurance Company
Group #
ID#
Dep#
Insurance Coverage (%)
A. Coverage %
B. Coverage %
C. Coverage %
D. Coverage %
Deductible Amount ($)
Annual Limit
Policy Holder's Name
Date of Birth (Policy Holder)

Month Day Year
Date
SIN of Policy Holder
Policy Holder's Employer
Phone
Insurance Company
Group #
ID#
Dep#
Insurance Coverage (%)
A. Coverage %
B. Coverage %
C. Coverage %
D. Coverage %
Deductible Amount ($)
Annual Limit
Policy Holder's Name
Date of Birth (Policy Holder)

Month Day Year
Date
SIN of Policy Holder
Policy Holder's Employer
Phone
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? Is it controlled?
Do you have pains in your chest?
Have you ever had any major operations? Please specify.
Have you ever been involved in a serious accident? What kind?
Do you bruise or bleed easily?
Do you smoke? How much?
Any drug allergies? If yes, what drugs?
For WOMAN only, are you pregnant?
Please tell us any medical conditions that you have (e.g. Diabetes, Arthritis etc.)

Hepatitis Sinusitis Arthritis Diabetes Epilepsy Anemia Asthma ARC/AIDS (HIV) Muscular dystrophy Multiple Sclerosis (MS) Psychiatric care Thyroid disease Immune disorders Tuberculosis/Lung disease Blood disorders Venereal disease Heart problem or stroke Kidney/Liver disease Gastrointestinal disease Abnormal blood pressure Rheumatic fever or heart murmur Artificial joint or valves Radiotherapy or chemotherapy Mental or nervous disease Other diseases
How can I help you?
Good or Bad Experiences?
Childhood, regular dental care?

Yes No
Last Visit
Reason
Problems you are aware of
Are conditions getting worse?
How many times do your brush daily?

1 2 3
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?
If you have neck or shoulder pain, how severe?
If you have neck or shoulder pain, how frequent is it?
Have you ever had orthodontic treatment?

No Yes
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.

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

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

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

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

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

Yes No
Are your teeth:

Chipped? Protruding? Hidden?
What would you like to change the most in the appearance of your teeth?
Permit of Operation This is to certify that I, undersigned, 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 and I will assume responsibility for fees associated with those procedures
Patient's (Parent's) signature

Clear
Date

Month Day Year
Date
Should be Empty:

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Dental Insurance

Medical History