Medical History & Patient Registration

MEDICAL HISTORY & PATIENT REGISTRATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number (Home)*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Mobile)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Who referred you to our office?
INSURANCE INFORMATION:

If you have dental insurance, kindly provide the following information:
Insurance Company
Plan/Group Number
Certificate Number
Name of Plan Holder
Plan Holder’s Date of Birth

MonthDayYear
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
Name*

First NameLast Name
Relationship*
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Mobile)*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Family Doctor*
Phone or Address*
(1) Name of Medical Specialist
Area of Specialty
Phone or Address
(2) Name of Medical Specialist
Area of Specialty
Phone or Address
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.
YesNoNot Sure/Maybe
2. When was your last medical checkup?*
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
Medications
Latex / Rubber Products
Other (eg. hay fever, seasonal/environmental, foods)
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
Chest pain, anginaHeart attackStroke, TIAHeart murmurRheumatic feverMitral valve prolapseTuberculosisCancerPacemakerLung diseaseStomach ulcersArthritisSteroid therapyDiabetesThyroid diseaseDrug/alcohol/cannabis use or dependencySeizures (epilepsy)Kidney diseaseShortness of breathOsteoporosis medications (eg. Fosamax, Actonel)
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
YesNoNot Sure/Maybe
Expected delivery date:
YesNoNot Sure/Maybe
Patient/Parent/Guardian Signature*

Clear
PRIVACY POLICY ACT - PATIENT CONSENT FORM
FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
To the best of my knowledge, the above information is correct:
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL HISTORY & PATIENT REGISTRATION

INSURANCE INFORMATION:

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

Medical History

PRIVACY POLICY ACT - PATIENT CONSENT FORM

To the best of my knowledge, the above information is correct: