New Patient Form

New Patient Form

Welcome to Cumberland Dental! Below are our office policies
We require a minimum of 24 hours notice to cancel OR change any appointment. A fee will be charged if an appointment is missed or cancelled without sufficient notice.We offer a reminder notice the day before your appointment. Please note that this is a courtesy notice. If you do not receive our notice, you are ultimately responsible for missing the appointment that you scheduled.Our office provides electronic/manual billing to your insurance company on your behalf. You are responsible for providing the necessary information in order for us to direct bill your insurance company as well as informing us of any changes in thisinformation.Due to the privacy act, you are responsible to monitor your plan’s coverage and maximums. If your insurance does not cover your treatment, you are responsible to cover the cost at the time each service is rendered unless other arrangements have been made.All fees charged are those set out by the College of Dental Surgeons of Saskatchewan.
I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and will assume responsibility for fees associated with these procedures. I have read and agree with the policies of Cumberland Dental.
Signature
Date

MonthDayYear
Patient Registration
Title

Dr.Mr.Mrs.Ms.Miss.
Name

Last First | Middle Initial
Preferred Name
Date of Birth

MonthDayYear
Date
Sex

MaleFemale
Preferred Pronouns

He/HimShe/HerThey/Them
Saskatchewan Health #
Treaty Status #
Address

Apt. | Street Address

CityProvince

Postal Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
Occupation
Employer
In case of emergency, notify
Name Relationship
Phone Number
Format: (000) 000-0000.
Method of Payment for Dental Treatment

Debit/CreditSocial ServicesIndian AffairsDental Insurance * Please provide reception with insurance card.
If not you, person responsible for account:
Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Apt. | Street Address

Street Address Line 2

CityProvince

Postal Code
Other family members who come to our office
How do you prefer to be contacted for your appointments?

PhoneTextEmail
How did you hear about us?
Friends Name, Online, Other - Please Specify
Medical History
1. Are you presently in good health? Date of last medical examination

MonthDayYear
Date
YesNo
2. Have you ever had a serious illness requiring hospitalization or extensive care? If yes, explain
3. Is a physician treating you now?

YesNo
4. Are you taking any kind of medication? Please list
5. Have you ever experienced an unusual reaction to

AspirinPenicillinCodeineMetal, Plastics, LatexTylenolSulphaIbuprofenOther
6. Do you have or have you ever had:

AIDS/ARC/HIVHepatitis A/BSinus TroubleHay FeverOrgan TransplantsArthritisHerpes/Cold SoresStrokeMental/NervousTuberculosisAsthmaHeart ProblemsSTDThyroid DiseaseCancerHeart MurmurMultiple SclerosisSevere HeadachesDiabetesStomach UlcersRheumatic FeverEpilepsy/SeizuresJoint ReplacementBlood DisordersOther
7. Do you have allergies? Please specify:
8. Do you bruise or bleed easily?

YesNo
9. Do you ever have chest pains or shortness of breath?

YesNo
10. Have you ever had radiation or chemotherapy?

YesNo
11. Have you ever fainted?

YesNo
12. Do you smoke?

YesNo
13. Are you pregnant? If so, which month?
14. Are you nursing?

YesNo
15. Are you taking birth control pills?

YesNo
Dental Health
1. Reason for present dental visit:
2. Do you have or have you ever had:

FillingsRoot CanalsToothachesGum DiseaseDenturesCrownsBridgesOrthodonticsTMJ ProblemsOral SurgeryTrauma to the head/neck
3. Are any of your teeth sensitive to:

HeatColdSweets
4. Do you clench or grind your teeth?

YesNo
5. Do you have pain or hear any noises in your jaw joints?

YesNo
6. Has your jaw ever locked open or closed?

YesNo
7. Have you had any troubles with local anesthetic (freezing)?

YesNo
8. How often do you brush?
x per day
9. How often do you floss?
x per week
10. How frequently do you see the dentist?

6 monthsYearly
11. Last Dental Visit
12. Are you concerned with the appearance of your teeth? If so, specify
13. Is there any other information that should be known about your health or previous dental visits?
Should be Empty:

New Patient Form

Patient Registration

Medical History

Dental Health