New Patient Form - Everbrite Dental

Name*

TitleFirst NameLast Name
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Home Phone
Mobile*
Work Phone
Street Address:*
City, Province*
Postal Code*
Occupation
Employer
Referred By
Emergency Contact*
Emergency Contact Number*
Are you being treated for any medical conditions at the present time or have been treated within the last year?*

YesNoNot Sure
If so why
When was your last medical checkup*
Have there been any changes in your general health in the last year?*

YesNoNot Sure
If yes please explain
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

YesNoNot Sure
If yes please list
Do you have any allergies? If you answered yes, please list using the categories below:*

YesNoNot Sure
Medications
Latex/Rubber Products
Other (e.g. Hayfever Foods)
Have you ever had an uncommon or adverse reaction to any medicines or injections?*

YesNoNot Sure
If yes please explain
Do you have or have you ever had asthma?*

YesNoNot Sure
Type of Puffer:
Do you have or have you ever had any heart or blood pressure problems?*

YesNoNot Sure
Do you have or have 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?*

YesNoNot Sure
Have you ever had hepatitis, jaundice or liver disease?*

YesNoNot Sure
Which type of hepatitis
Do you have a prosthetic or an artificial joint?*

YesNoNot Sure
If yes please explain
Do you have a bleeding problem or a bleeding disorder?*

YesNoNot Sure
If yes please explain
Have you ever been hospitalized for any illness or operations?*

YesNoNot Sure
If yes please explain
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?*

YesNoNot Sure
Do you have or have you ever had any of the following? Please Check

AIDSDigestive Disorders/ Acid RefluxHypo/ HyperglycemiaSexually Transmitted InfectionAlzheimersDrug/Alcohol DependencyKidney DiseaseShortness of BreathAnginaEmphysemaLung DiseaseSleep ApneaAnemiaEpilepsy or SeizuresLupusSteroid TherapyArthritisFibromyalgiaMigraineStomach UlcersBlood TransfusionHead/Neck InjuryMitral Valve ProlapseStrokeCancerHeart AttackOsteoporosis Medications (e.g. Fosamax, Actonel)ThrushChest PainHeart MurmurPacemakerThyroid DisorderCold SoresHigh/Low Blood PressureParkinsons DiseaseTMJ DisorderDiabetes Type 1HIVRadiation/ ChemotherapyTuberculosisDiabetes Type 2Hodgkins DiseaseRheumatic Fever
Are there any conditions or disease not listed above that you have or have had?*

YesNoNot Sure
If yes please list
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)*

YesNoNot Sure
If yes please explain
Do you smoke or chew tobacco products?*

YesNoNot Sure
Are you nervous during dental treatment?*

YesNoNot Sure
If yes please explain
For Women: Are you pregnant?

YesNo
Note
The Information I have given above is true to the best of my knowledge
Patient Signature*

Clear
Date*

MonthDayYear
Date
PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organization. We do this for purposes such as:

To provide you with health care;

To get payment for your care which could include private insurers;

To do health system planning and research;

To report as required by law;
Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.
Date

MonthDayYear
Date
Should be Empty: