WELCOME TO OUR OFFICE
Patient Information
A parent or guardian will be responsible for decisions on my treatment
Yes
No
Name:
First Name
Middle Initial
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
-
Month
-
Day
Year
Date Picker Icon
Gender
M
F
Other
Cell Phone #
Format: (000) 000-0000.
Work #
Format: (000) 000-0000.
E-mail:
example@example.com
Health Card Number:
Treaty Card Number:
Emergency Contact:
Format: (000) 000-0000.
Emergency Tel:
Format: (000) 000-0000.
Family Doctor:
Format: (000) 000-0000.
Family tel:
Format: (000) 000-0000.
INSURANCE
Ins Company: (you may present your insurance card to receptionist)
Employer/ Policy Holder:
Ins Yr. End
Policy #
Div/Sec #
ID #
Cardholder Name:
Card Type:
Visa
MasterCard
American Express
Other
Card Number :
Expiry Date (MM/YY) :
CVV :-
I authorize this dental office to securely keep my credit card on file. I understand that I remain responsible for any balances not covered by insurance. I understand that the office will contact me to obtain my permission prior to charging any outstanding balance to my credit card
Cardholder Signature:
Date:
-
Month
-
Day
Year
Date
Dental History
1. What is the reason for today's visit?
Emergency
Examination
Other
Other
2. How frequently do you see the dentist?
3-6 months
Annually
Other
Other
3. When was your last dental visit?
Last X-ray?
4. How often do you brush per day?
Floss?
Use anti-bacterial rinse?
5. Are your teeth sensitive to:
Cold
Sweets
Heat
Other
Other
6. Do your gums bleed when:
Brushing
Flossing
Never
Rows
Yes
No
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 complications?
Yes
No
Specify
Medical History
Back
Next
(This information will remain confidential)
1. Are you presently under the care of a physician?
Yes
No
If so, explain
2. Have you ever been hospitalized?
Yes
No
Explain
3.Are you taking any drugs or medication currently?
Yes
No
Drug
Reson
4. Have you been diagnosed with sleep apnea or do you experience symptoms of sleep apnea?
Yes
No
5.Have you ever been warned against using any other medications
Yes
No
Which?
6. Have you ever taken prolonged medical or non-medical drugs?
Yes
No
Which?
7. Do you suffer from any allergies (hay fever, latex etc.)?
Yes
No
Which?
8. Do you bruise easily or have prolonged bleeding?
Yes
No
9. Do you smoke or vape?
Yes
No
How much per day?
10. Have you ever fainted, had shortness of breath, or chest pains?
Yes
No
11. WOMEN:
Are you pregnant?
Yes
No
Using birth control?
Yes
No
Reached menopause?
Yes
No
12. Do you have or have you had any of the following? Please check appropriate boxes.
NONE
A.I.D.S.
Anaemia
Angina pectoris
Anorexia nervosa
Arthritis/rheumatism
Artificial heart valve
Artificial joints (hip, knee)
Asthma
Blood disorders
Bronchitis
Bulimia
Cancer
Circulation problems
Congenital heart lesions
Cortisone/Steroids
Diabetes
Drug/Alcohol dependence
Emphysema
Epilepsy or seizures
Glandular disorders
Glaucoma
Head/Neck injuries
heart disease/Attack
Heart murmur
Heart pacemaker/Surgery
Heart rhythm disorder
Hepatitis A.B.C.
Herpes
High/Low blood pressure
H.I.V. Positive
Hodgkins's disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
kidney disease
Liver disease
Lung disease
Malignant hyperthermia
Mental/nervous disorder
Mitral valve prolapses
Organ transplant/implant
Psychiatric treatment
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell disease
Sinus trouble
Stomach/Intestinal problems
Stroke
Thyroid disease
Tuberculosis
Ulcers
Venereal Disease
Other
13. CHILDREN: Have you recently had any of the following (approximate date)?
Chicken Pox
Measles
Mumps
Strep Throat
Tonsillitis
NONE
Approximate Date
-
Month
-
Day
Year
Date
Approximate Date
-
Month
-
Day
Year
Date
Approximate Date
-
Month
-
Day
Year
Date
Approximate Date
-
Month
-
Day
Year
Date
Approximate Date
-
Month
-
Day
Year
Date
Approximate Date
-
Month
-
Day
Year
Date
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 it is my responsibility to pay for dental treatment for both me and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures. I understand that the treatment offered to me is tailored to my needs. All treatment options will be discussed before treatment is delivered.
SIGNATURE
SELF
PARENT/GUARDIAN
PRINT NAME
DATE
-
Month
-
Day
Year
Date
Submit
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