videntalspecialists.com - VIDS NEW PATIENT INTAKE FORM

Patient Name:*

Family Dentist:

Personal Health Card Number:*

Patient phone number/preferred number*

Please enter a valid phone number.

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Please enter a valid phone number.

Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code

Physicians Name/Clinic Name

Physicians Phone Number

Please enter a valid phone number.

Add Dental Insurance Information Below:

First Insurance Policy Holders Name:

First Insurance Policy Holders Insurance Company Name: ie: Sunlife/Manulife/Canada Life

First Insurance Policy Holders Date of Birth:

Date

First Insurance Policy Holders Group Number:

First Insurance Policy Holders ID/Certificate Number:

Second Insurance Policy Holders Name:

Second Insurance Policy Holders Date of Birth:

Date

Second Insurance Policy Holders Insurance Company Name: ie: Sunlife/Manulife/Canada Life

Second Policy Holders Group Number:

Second Policy Holders ID/Certificate Number:

When was the last time you had a medical examination?*

Provide a DETAILED list of your medical history: (ie: high blood pressure, pacemaker, asthma, history of breast cancer, history of stroke, pre-diabetic, depression, artificial hip etc)*

Height:*

Weight:*

Are you presently receiving treatment for any illness?*

YesNo

If yes, please provide details*

Are you presently taking any kind of medication?*

YesNo

Please specify the name of drug and reason.*

Do you have medication/food or other allergies.*

YesNo

List medication/food or allergies:*

Have you ever been advised by your medical physician or specialist to ALWAYS take antibiotic pre-medication prior to EVERY dental treatment?*

YesNo

Have you ever had a reaction to any kind of medicine or dental local anesthetic?*

YesNo

Have you ever smoked cigarettes/marijuana or vape? (ie: Yes, 1/2 pack per day for 20 years)*

Do you have sleep apnea or use a cpap machine?*

YesNo

What can we help you with? (ie: bleeding gums, missing teeth, dentist noticed bone loss, want to replace missing teeth)*

Have you ever had periodontal treatment (ie: gum grafting, implants)*

YesNo

How often do you have hygiene visits (ie: 2x year)*

Have you ever had orthodontic treatment? (ie: braces, Invisalign)*

How often do you brush per day?*

What type of toothbrush are you using? (manual vs Oral B, Sonicare...)*

Are you aware if you clench or grind your teeth? Do you wear a nightguard?*

YesNo

Are you pregnant?*

YesNo

Is there any additional information related to your health that has not been addressed above?*

How did you hear about us: General Dentist/Coffee News/Internet/Friend/Other

CONSENT TO COLLECT, USE AND DISCLOSE PERSONAL HEALTH INFORMATION:
In accordance with PIPEDA (Personal Information Protection and Electronic Documents Act) I authorize VI Dental Specialists to collect personal information relating to my dental and medical health. I understand this information is required to allow for proper evaluation, diagnosis and treatment of oral and dental health conditions.

I consent to the communication of information to my referring dentist, other dental specialists, my physician(s), dental laboratories; my dental benefits plan administrator, insurance carrier, and the Canadian Dental Association, when necessary. The information may be transferred to myself and the necessary individuals via phone, mail, fax or email/internet.

This information may include clinical records, x-rays, diagnostic models, general health information obtained from a medical history review, insurance information, consent forms, phone numbers, addresses and photographs of my teeth / mouth / smile / face. Clinical information, photographs and x-rays may also be used for long-term follow-up and research, as well as for education or teaching purposes.

VI Dental Specialists recognizes the importance of personal information protection and makes every effort possible to safeguard this information.

Cancellation/missed appointment policy: When you schedule an appointment, we reserve that time just for you with our dental staff and doctor. We are committed to honoring the appointment time of our scheduled patients, so it is critical that you confirm and arrive on time. We will be unable to hold your reserved time if you have not confirmed. We require 2 business days notice to change or cancel a consultation appointment ~ Inadequate notice fee is $100.00 - $150.00

I, the undersigned, have completed the above questionnaire and/or update and that it is accurate to the best of my knowledge.

I, hereby certify that I have read and understand this document.

Signature*

VIDS NEW PATIENT INTAKE FORM

MEDICAL HISTORY