Patient Registration Form

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
What title do you go by?

Other
Last Name
First Name
Initials (First and Last)
Address

Street Address

CityProvince

Postal
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Provincial Health No.
Occupation / Employer
Work Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Home Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Cell Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Person responsible for account:
If other, please complete the following:
Name

First NameLast Name
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Physician Information
Family Physician
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Medical Specialist
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.

Do you have dental insurance?
Insurance
Name of Insured
Date of Birth

MonthDayYear
Employer
Insurance Company
Group/Policy No.
Division
I.D. Number
Certificate No.
Dep. No.

Deductible

Rows Basic Major

Deductible
Deductible type
Do you have secondary dental insurance?
Name of Insured (2)
Date of Birth (2)

MonthDayYear
Employer (2)
Insurance Company (2)
Group/Policy No. (2)
Division (2)
I.D. Number (2)
Certificate No. (2)
Dep. No. (2)

Rows	Basic	Major
Deductible

Coverage Percentage (2)

Rows	A	B	C	D
Percentage

Limits (2)

Rows	Basic	Major	Ortho
Limits

Deductible (2)

Rows Basic Major

Deductible
Deductible Type 2

Rows	Basic	Major
Deductible

Emergency and Referral
In case of emergency, please notify
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Is another family member or relative a patient at our office?
Whom may we thank for referring you?

Patient Registration Form
Guarantees
Dentistry is not an exact science; there are many unforeseen variables, thus, planned treatment results are not always attainable, risks may be involved regardless of the expertise of the dentist. We do stand behind our work, and we will make every reasonable effort to be fair. Our goal is to provide quality dentistry for our patients. We will not be held responsible for unsatisfactory treatment results caused or contributed by a patient's failure to take reasonable care or to follow our advice. If instructions in a given situation are unclear, we encourage you to ask questions.
Respectful Behaviour Policy
At our practice, we are committed to creating a safe, inclusive, and respectful environment for all patients, families, and staff. We ask that all individuals treat one another with courtesy and kindness, regardless of background, identity, or circumstance. Disrespectful, aggressive, or discriminatory language or behaviour will not be tolerated and may result in the rescheduling or cancellation of appointments. We appreciate your partnership in helping us maintain a welcoming space for everyone.
Appointment Cancellation Policy
We understand that schedules can change. If you need to cancel or reschedule your appointment, we kindly ask that you provide at least 24 hours' notice. This allows us to offer your appointment time to another patient. Cancellations with less than 24 hours' notice, or missed appointments without notice, may be subject to a fee.
Medication and Substance Disclosure
For your safety, it is essential that you inform us of all medications, supplements, and substances you have taken prior to your appointment, including alcohol, cannabis, and other prescription or street drugs. Some substances can affect the safety and effectiveness of dental treatments or procedures. Full disclosure helps us provide you with the best and safest care possible. If you arrive under the influence of substances that may impair your judgment or ability to receive treatment safely, we may need to reschedule your appointment. We ask that you refrain from wearing perfume or other fragrances to the clinic. These odors may trigger asthma, rhinitis or migraines for some of our patients.
Dental Plans & Payments
Co-payments, co-insurance and deductibles are due at the time of your visit. If arrangements need to be made depending on your insurance coverage or if there are special circumstances, please see the front desk to make those arrangements prior to your appointment otherwise a $50 late payment administration fee will apply.
Insurance & Fees
Dental insurance coverage varies by carrier, plan, and procedure, so it's your responsibility to understand your policy's terms and exclusions. While we submit claims and quote estimates on your behalf, these are estimates only — actual coverage depends on the details you've provided and may be affected by annual limits, non-covered procedures, and other plan-specific factors (e.g., fee differences between amalgam and composite fillings, sealants, etc.). We accept direct payment from your insurer if your plan allows assignment of benefits to our office. If your insurer delays or fails to pay, the outstanding balance becomes your responsibility, and we'll direct future payments to you unless other arrangements were made before treatment.
Patient Certification & Consent
I certify that the medical and dental information I've provided is true and complete to the best of my knowledge, and I consent to my physician being contacted if needed for my dental care. Elements Clinic uses AI-assisted note-taking to record conversations with staff and patients, supporting our documentation and treatment planning. I consent to voice recordings for this purpose.
I consent to the dental and oral surgery procedures agreed upon with your office, including the use of local anaesthetic as indicated, and I accept responsibility for all associated fees and any interest on unpaid balances (18% per annum / 1.5% per month). I have read and understand the above and agree to these conditions. I understand that either party may choose to end the patient-dentist relationship if these conditions are not upheld.
Patient (Parent, Guardian) Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient name (Parent, Guardian):
*Guardian of Child or Guardian of Adult under Guardianship

Dental History
Name
Nickname
Age
Referred by
How would you rate the condition of your mouth?
Previous Dentist
How long have you been a patient?
Date of most recent dental exam

MonthDayYear
Date of most recent x-rays

MonthDayYear
Date of most recent treatment other than a cleaning

MonthDayYear
I routinely see my dentist every:
What is your immediate concern?

Rows	Yes	No
1. Hospitalization for illness or injury
3. Heart problems, or cardiac stent within the last six months
4. History of infective endocarditis
5. Artificial heart valve, repaired heart defect (PFO)
6. Pacemaker or implantable defibrillator
7. Orthopedic implant (joint replacement)
8. Rheumatic or scarlet fever
9. High or low blood pressure
10. A stroke (taking blood thinners)
11. Anemia or other blood disorder
12. Prolonged bleeding due to a slight cut (INR > 3.5)
13. Pneumonia, emphysema, shortness of breath, sarcoidosis
14. Chronic ear infections, tuberculosis, measles, chicken pox
15. Asthma
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. Kidney disease
18. Liver disease
19. Jaundice
20. Thyroid, parathyroid disease, or calcium deficiency
21. Hormone deficiency
22. High cholesterol or taking statin drugs
24. Stomach or duodenal ulcer
25. Digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. Arthritis
28. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
29. Glaucoma
30. Contact lenses
31. Head or neck injuries
32. Epilepsy, convulsions (seizures)
33. Neurologic disorders (ADD/ADHD, prion disease)
34. Viral infections and cold sores
35. Any lumps or swelling in the mouth
36. Hives, skin rash, hay fever
37. STI/STD/HPV
39. HIV/AIDS
40. Tumor, abnormal growth
41. Radiation therapy
42. Chemotherapy, immunosuppressive medication
43. Emotional difficulties
44. Psychiatric treatment
45. Antidepressant medication
46. Alcohol/recreational drug use
47. Presently being treated for any other illness
48. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
49. Taking medication for weight management
50. Taking dietary supplements
51. Often exhausted or fatigue
52. Experiencing frequent headaches
53. A smoker, smoked previously or use smokeless tobacco
54. Considered a touchy/sensitive person
55. Often unhappy or depressed
56. Taking birth control pills
57. Currently pregnant
58. Diagnosed with a prostate disorder

Rows	Yes	No
Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?

Rows	Yes	No
Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own, or do you have difficulty eating an apple?
Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Rows	Yes	No
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, had a toothache or cracked filling?
Do you frequently get food caught between any teeth?

Rows	Yes	No
Do you have problems with your jaw joint?
Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
Do you avoid or have difficulty chewing hard, dry foods?
In the past 5 years, have your teeth changed or has your bite changed?
Are your teeth becoming more crooked, crowded, or overlapped?
Are your teeth developing spaces or becoming more loose?
Do you have trouble finding your bite?
Do you place your tongue between your teeth or close your teeth against your tongue?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench or grind your teeth together in the daytime or make them sore?
Do you have any problems with sleep?
Do you wear or have you ever worn a bite appliance?

If other, please complete the following:

Physician Information

Insurance

Emergency and Referral

Patient Registration Form

Guarantees

Respectful Behaviour Policy

Appointment Cancellation Policy

Medication and Substance Disclosure

Dental Plans & Payments

Insurance & Fees

Patient Certification & Consent

Medical History

Do You Have or Have You Ever Had:

Dental History

Dental History Questions

Rows	Yes	No
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

Rows	Drug	Purpose
1
2
3
4
5
6