New Patient Paperwork

Patient Name:
Nickname:
Age:
Referred By:
DENTAL HISTORY
How would you rate the condition of your mouth?

ExcellentGoodFairPoor
Previous Dentist:
Date of most recent dental exam:

MonthDayYear
Date
Date of most recent x-rays:

MonthDayYear
Date
Date of most recent treatment (other than a cleaning):

MonthDayYear
Date
I routinely see my dentist every:

3 mo4 mo6 mo12 monot routinely
WHAT IS YOUR IMMEDIATE CONCERN?
Personal History
1. Are you fearful of dental treatment?

YesNo
How fearful, on a scale of 1 least to 10 most
2. Have you had an unfavorable dental experience?

YesNo
3. Have you ever had complications from past dental treatment?

YesNo
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

YesNo
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?

YesNo
6. Have you had any teeth removed?

YesNo
Gum and Bone
7. Do your gums bleed or are they painful when brushing or flossing?

YesNo
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

YesNo
9. Have you ever noticed an unpleasant taste or odor in your mouth?

YesNo
10. Is there anyone with a history of periodontal disease in your family?

YesNo
11. Have you ever experienced gum recession?

YesNo
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

YesNo
13. Have you experienced a burning sensation in your mouth?

YesNo
Tooth Structure
14. Have you had any cavities within the past 3 years?

YesNo
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

YesNo
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

YesNo
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

YesNo
18. Do you have grooves or notches on your teeth near the gum line?

YesNo
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

YesNo
20. Do you frequently get food caught between any teeth?

YesNo
Bite and Jaw Joint
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

YesNo
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?

YesNo
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

YesNo
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?

YesNo
25. Are your teeth becoming more crooked, crowded, or overlapped?

YesNo
26. Are your teeth developing spaces or becoming more loose?

YesNo
27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

YesNo
28. Do you place your tongue between your teeth or rest your teeth against your tongue?

YesNo
29. Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits?

YesNo
30. Do you clench your teeth in the daytime or make them sore?

YesNo
31. Do you have any problems with sleep? (i.e. restlessness), wake up with a headache or an awareness of your teeth?

YesNo
32. Do you wear or have you ever worn a bite appliance?

YesNo
Smile Characteristics
33. Is there anything about the appearance of your teeth that you would like to change?

YesNo
34. Have you ever whitened (bleached) your teeth?

YesNo
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?

YesNo
36. Have you been disappointed with the appearance of previous dental work?

YesNo
Patient’s Signature

Clear
Today's Date

MonthDayYear
Date
MEDICAL HISTORY
Name of Physician/and their specialty
Most recent physical examination
What is your estimate of your general health?

ExcellentGoodFairPoor
DO YOU HAVE or HAVE YOU EVER HAD:
1. hospitalization for illness or injury

YesNo
2. an allergic reaction to:

Aspirin, ibuprofen, acetaminophen, codeinePenicillinErythromycinTetracyclineSulfaLocal anestheticFluorideMetals (nickel, gold, silver)LatexOther
3. heart problems, or cardiac stent within the last six months

YesNo
4. history of infective endocarditis

YesNo
5. artificial heart valve, repaired heart defect (PFO)

YesNo
6. pacemaker or implantable defibrillator

YesNo
7. orthopedic implant (joint replacement)

YesNo
8. rheumatic or scarlet fever

YesNo
9. high or low blood pressure

YesNo
10. a stroke (taking blood thinners)

YesNo
11. anemia or other blood disorder

YesNo
12. prolonged bleeding due to a slight cut (INR > 3.5)

YesNo
13. emphysema, shortness of breath, sarcoidosis

YesNo
14. tuberculosis, measles, chicken pox

YesNo
15. asthma

YesNo
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)

YesNo
17. kidney disease

YesNo
18. liver disease

YesNo
19. jaundice

YesNo
20. thyroid, parathyroid disease, or calcium deficiency

YesNo
21. hormone deficiency

YesNo
22. high cholesterol or taking statin drugs

YesNo
23. diabetes HbA1c

YesNo
24. stomach or duodenal ulcer

YesNo
25. digestive disorders (i.e. celiac disease, gastric reflux)

YesNo
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)

YesNo
27. arthritis

YesNo
28. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)

YesNo
29. glaucoma

YesNo
30. contact lenses

YesNo
31. head or neck injuries

YesNo
32. epilepsy, convulsions (seizures)

YesNo
33. neurologic disorders (ADD/ADHD, prion disease)

YesNo
34. viral infections and cold sores

YesNo
35. any lumps or swelling in the mouth

YesNo
36. hives, skin rash, hay fever

YesNo
37. STI/STD/HPV

YesNo
38. hepatitis

YesNo
39. HIV / AIDS

YesNo
40. tumor, abnormal growth

YesNo
41. radiation therapy

YesNo
42. chemotherapy, immunosuppressive medication

YesNo
43. emotional difficulties

YesNo
44. psychiatric treatment

YesNo
45. antidepressant medication

YesNo
46. alcohol / recreational drug use

YesNo
ARE YOU:
47. presently being treated for any other illness

YesNo
48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)

YesNo
49. taking medication for weight management

YesNo
50. taking dietary supplements

YesNo
51. often exhausted or fatigued

YesNo
52. experiencing frequent headaches

YesNo
53. a smoker, smoked previously or use smokeless tobacco

YesNo
54. considered a touchy / sensitive person

YesNo
55. often unhappy or depressed

YesNo
56. FEMALE - taking birth control pills

YesNo
57. FEMALE - pregnant

YesNo
58. MALE - prostate disorders

YesNo
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years.
Patient’s Signature

Clear
Date

MonthDayYear
Date
CONFIDENTIAL PATIENT RECORD
Date of Birth:

MonthDayYear
Date
Phone Number - Home
Please enter a valid phone number.
Phone Number - Cell
Please enter a valid phone number.
Phone Number - Work
Please enter a valid phone number.
Address: Street, City, Postal Code
Email
example@example.com
Preferred Contact:
Referred By:
In case of emergency, Call
Emergency contact Phone Number
Please enter a valid phone number.
PRIMARY INSURANCE
PRIMARY CARRIER
Employer
Policy Number
Certificate Number
Policy Holders Name
Date of Birth of Policy Holder

MonthDayYear
Date
SECONDARY INSURANCE (if applicable)
SECONDARY CARRIER
Employer
Policy Number
Certificate Number
Policy Holders Name
Date of Birth of Policy Holder

MonthDayYear
Date
FOR PATIENTS 15 YEARS AND UNDER ONLY
Health Card Number
EDI SIGNATURE AND ASSIGNED SIGNATURE:
I hereby assign my benefits; payable from claims submitted electronically to my dentist and authorized payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.

Patient (Parent/ Guardian) I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. The authorization shall continue in effect until the undersigned revokes the same.
I hereby assign my benefits; payable from claims submitted electronically to my dentist and authorized payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.

Clear
I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. The authorization shall continue in effect until the undersigned revokes the same.

Clear
PATIENT CONSENT
I, the undersigned, certify that the medical and dental information I provide is true to my knowledge and I have not omitted any pertinent information. I consent to the preforming of dental procedure agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.

Clear
Date

MonthDayYear
Date
CONSENT TO TRANSFER PATIENTS RECORDS
I hereby request and authorize the release of my dental records to Hammond Dental Centre.

Complete dental records including patient chart, radiographs, models, photographs and any other documentation including referral letters and correspondence with specialists and/or insurance complanies.

Please mail or email, if electronic files, to the address or email listed above.

I understand that only copies of my records and duplicates of my radiographs and models will be provided and that if no duplicates can be made, that the originals will be forwared to the address listed in the letterhead and retruned to the sending dentist. I agree to pay any fees that may occur in the transferring of my records, including the duplication of radiographs and models if neccessary.
Previous Dental Office and Dentist's Name
Patient/Parent or Guardian Signature

Clear
FEES AND CANCELLATION POLICY
We try earnestly to offer friendly and timely service that accommodates your needs, and to continue to maintain this effort our practice requires a minimum of two business days’ notice to change or cancel a reserved appointment, or a rescheduling fee will apply.

This appointment time has been reserved specifically for you, when an appointment is missed it not only affects the doctor or hygienists, it affects the patient who has been waiting for an appointment time.

While we make every effort to contact patients in the days preceding their appointments, this

confirmation is a courtesy and does not eliminate the responsibility of the patient to attend their

If you need to change/ cancel an appointment, please call and speak with one of our staff members, or leave us a message on our voicemail at 902-835-1031

Please understand this policy benefits everyone. Help us be available for you!

I have read and understand the Fees and Cancellation Policy
Signature

Clear
Should be Empty:

DENTAL HISTORY

Personal History

Gum and Bone

Tooth Structure

Bite and Jaw Joint

Smile Characteristics

MEDICAL HISTORY

DO YOU HAVE or HAVE YOU EVER HAD:

ARE YOU:

CONFIDENTIAL PATIENT RECORD

PRIMARY INSURANCE

SECONDARY INSURANCE (if applicable)

FOR PATIENTS 15 YEARS AND UNDER ONLY

EDI SIGNATURE AND ASSIGNED SIGNATURE:

PATIENT CONSENT

CONSENT TO TRANSFER PATIENTS RECORDS

FEES AND CANCELLATION POLICY