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  • Patient Information

  • Date Of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Financial Information

  • Person responsible for financial matters:

  • Primary Insurance

  • Policy Holder:
  • Date of Birth:
     - -

  • Secondary Insurance

  • Date of Birth:
     - -

  • Family Dentistry at Picton 45 Main Street, Picton, ON KOK 2T0 (613)476-3466
    www.FamilyDentistryatPicton.com

  • Medical History

  • 1. Are you presently under the care of a physician?
  • 2. Have you ever been hospitalized?
  • 3. a)Are you taking any drugs or medication at this time?
  • b)Are you taking weight loss medications at this time?
  • 4. Have you ever had any adverse effect to any of the following
  • 5. Have you ever been warned against using any other medications?
  • 6. Have you ever taken prolonged medical or non-medical drugs?
  • 7. Do you suffer from any allergies (hay fever, latex etc.)
  • 8. Do you bruise easily or have prolonged bleeding?
  • 9. (a)Do you smoke?
  • (b)Do you use Marijuana?
  • 10. Have you ever fainted, had shortness of breath or chest pains?
  • 11. Are you pregnant?
  • Using birth control?
  • Reached menopause?
  • Family Dentistry at Picton 45 Main Street, Picton, ON KOK 2T0 (613)476-3466 www.FamilyDentistryatPicton.com

  • 12. Do you have or have you ever had any of the followings? Please select appropriate boxes.

  • Do you have or have you ever had any of the followings?

  • 13. CHILDREN Have you recently had any of the following (include approximate date):

  • Have you recently had any of the following (include approximate date):
  • Family Dentistry at Picton 45 Main Street, Picton, ON K0K 2T0 (613)476-3466 www.FamilyDentistryatPicton.com

  • Dental History

  • 1. What is the reason for today's visit?
  • 2. How frequently do you see dentist?
  • 5. Are your teeth sensitive to?
  • 6. Do your gum bleed when:
  • 7. Do your gums feel swollen or tender?
  • 8. Do you have bad breath or a bad taste in your mouth?
  • 9. Do your jaws crack, pop or grate when you open widely?
  • 10. Do you grind or clench your teeth?
  • 11. Do you have food catch between your teeth?
  • 12. Have you ever had local anaesthetic (freezing)?
  • Any complication with Anaesthetic (freezing)?
  • 13. Have you ever had any problems with previous dental treatments?
  • 14. Have you ever had any of the following:
  • 15. Are you satisfied with your teeth?
  • Family Dentistry at Picton 45 Main Street, Picton, ON KOK 2T0 (613)476-3466 www.FamilyDentistryatPicton.com

  • General Release

  • I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment.
  • I understand that if I miss an appointment or provide less than 48 hours (2 business days) notice to cancel or reschedule an appointment, I will be charged a cancellation fee. Please note that insurance companies do not cover fees for missed/cancelled appointments. Therefore, it will be patient's responsibility to pay such fees.
  • I understand that it is my responsibility to pay for dental treatment for both myself and my dependent. I assume all responsibility for fees associated with my dental treatment of dental diagnostic procedures. We will assist you in preparing insurance claim forms, along with requesting reimbursements from your insurance company, on your behalf. Be aware that not all services may be covered by your insurance company, no two plans are the same. We will work with you to help clarify your plan. However, it is the responsibility of the patient to understand his or her own dental insurance benefits. Services are to be paid for at each visit, as they are performed.
  • I have read and fully understand the above terms and conditions and I accept my responsibility as a patient at this office.
  • Date
     - -
  • Date
     - -
  • Family Dentistry at Picton 45 Main Street, Picton, ON K0K 2T0 (613)476-3466 www.FamilyDentistryatPicton.com
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