New Patient Registration Form 2025

info@hbirdsmiles.com
www.hummingbirdhygiene.com

office: 604.809.2881 fax: 833.806.2892
PATIENT REGISTRATION & HEALTH HISTORY
Date

MonthDayYear
Today
Patient Information
Name:*

First NameLast Name
Date of Birth:

MonthDayYear
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number (Primary Contact):*
Please enter a valid phone number.

INSURANCE INFORMATION:
Dental Insurance Provider:
Policy Number:
ID Number:
Name of Primary Card Holder:

First NameLast Name
Date of Birth (Primary Card Holder):

MonthDayYear
Payment Method
Payment Preference (choose one):*

E-transfer to payment@hbirdsmiles.comCredit CardCheque

General Consent & Release
I consent to the release of relevant medical information from the patient’s medical doctor, care facility, and healthcare providers, as required by Hummingbird Mobile Dental Hygiene Inc.

I authorize the dental hygiene team at Hummingbird to perform an oral assessment and providepreventive dental hygiene treatment. I also consent to the use of photographs or other diagnostic aids deemed necessary to complete a thorough evaluation of the patient’s oral health needs.

I understand that I am responsible for payment of all fees associated with this treatment. Accepted payment methods include credit card, e-transfer, or cheque.
Patient/Family Member or POA Name:*

First NameLast Name
Patient/Family Member or POA Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Relationship to Patient / Signing Authority:*

1. Are you aware of any of the following?*

	YES	NO
Current oral discomfort, pain, or concerns
Difficulty chewing
Presence of full or partial dentures

2. Approximate date of last dental exam or hygiene visit (if known):

MonthDayYear
Month/Day/Year
Daily Oral Care
Please describe the patient’s current oral care routine (to the best of your knowledge):
Additional Notes: Is there anything else we should be aware of prior to treatment?

YESNO
Additional Notes (If yes, please describe:)
Should be Empty:

	YES	NO
Headaches (Severe)
Head/Neck Injuries
Hearing Difficulties
Heart Attack
Heart Disease
Heart Pacemaker
Heart Rhythm Disorder
Hepatitis A / B / C
Infective Endocarditis
Kidney Disease
Liver Disease
Lung Disease
Medical Implant
Mitral Valve Prolapse
Organ Transplant
Osteoporosis
Psychiatric Treatment
Radiation / Chemotherapy
Rheumatic Heart Disease***
Stomach / Intestinal Problem
Stroke / TIA
Thyroid Disease
Tuberculosis
Other Neurodegenerative Diseases (e.g., Parkinson’s, Dementia)

PATIENT REGISTRATION & HEALTH HISTORY