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.
1. Are you currently being treated or have been treated for any medical condition within the past year? If yes, please explain.
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year? If yes, please explain.
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list all medications and indicate what condition is being treated.
5. Do you have any allergies? If yes, please list them using the categories below:
Medications
Latex / Rubber Products
Other (eg. hay fever, seasonal/environmental, foods)
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
7. Do you have or have you ever had asthma?
8. Do you have or have you ever had any heart or blood pressure problems?
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? If yes, please explain.
10. Do you have a prosthetic or artificial joint? If yes, please explain.
11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? If yes, please explain.
12. Have you ever had hepatitis, jaundice or liver disease?
13. Do you have a bleeding problem or bleeding disorder? If yes, please explain.
14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
15. Do you have or have you ever had any of the following? Please check.
16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)? If yes, please list them.
18. Do you smoke or chew tobacco products?
19. Are you nervous during dental treatment?
20. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
Expected delivery date:
21. Do you identify as a patient with a disability? If yes, please explain.
Patient/Parent/Guardian Signature
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
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: