Lotus Smile Dental(CN&EN)

Welcome to Lotus Smile Dental
欢迎光临康嘉牙医诊所
Please read this information before you continue(请确认您已阅读以下条款)*

Please enterEnglish, please do not enter any Chinese character. Type N/A if an item is notapplicable.请输入英文，请不要输入中文。请写N/A，如果这个问题不是适用于您。
PERSONAL INFORMATION 个人信息
Name 姓名(Please make sure yourname match with your Care Card,请确定您所输入的名字和医疗卡上面的名字是一致的)*

First Name 名字Last Name 姓氏
Date of Birth 出生日期*

MonthDayYear
Gender 性别*

Male 男性Female 女性
Address 地址*

Street Address Line 1 地址栏1

Street Address Line 2 地址栏2

City 城市State / Province 洲 / 省份

Postal / Zip Code 邮政编码
Phone Number 联系电话*
Home Phone Number 联系电话
E-mail 电子邮箱*
Referred by 推荐人
The person who referred you to Lotus Smile 推荐您来康嘉牙医诊所的人
Do you have dental coverage? 您是否有有牙医保险?

Yes 是No 否
DENTAL HISTORY 牙医历史
Please record previous dentist name if applicable(enter NA if not applicable): 您是否有之前看过的牙医的名字:(请写NA如果不适用于你)

First NameLast Name
Please record previous dentist phone number if applicable（Please enter 0 if not applicable）: 您是否有之前看过的牙医的电话:(请写0如果不适用于你)
Do you have any dental problems or concerns presently? 您现在是否有任何牙齿的问题和困惑?
Do you have sensitivity to temperature or pressure? 您是否有牙齿冷热敏感?*

YesNo
Do your gums bleed when you brush your teeth? 您是否每次刷牙的时候出现牙龈出血?*

YesNo
Do you grind/clench your teeth? 您是否出现夜间磨牙的情况?*

YesNo
Do you have any cracking or clicking of your jaw? 您是否下颌关节有响声?*

YesNo
MEDICAL HISTORY 医疗历史
Emergency Contact 紧急联系人名字*

First NameLast Name
Emergency Contact Phone 紧急联系人电话*
Relationship with Emergency Contact 与紧急联系人的关系*
(eg. Friends, Parents, Wife, Husbands, etc.)
Family Physician 家庭医生名字

First NameLast Name
Family Physician Phone 家庭医生电话
Personal Health Number (PHN) （if do not have PHN please enter 0000000000）医疗卡号码(请输入0000000000如果没有医疗卡号码)
Are you allergic to any medication? 您是否有对药物过敏?*

YesNo
If you are allergic to some medication, please specify the details(If not select NA): 如果有药物过敏的情况, 请说明是哪些药物:(如果没有药物过敏请选择NA)*

PenicillinAspirinCodeineDental anestheticsLatexNA
Are you taking any medication? 您是否有在吃的药物?*

YesNo
If you are taking medication, please specify the details: 如果有在吃的药物, 请说明是哪些药物:*
Do you have a history of a major illness? 您是否有重大的疾病或受伤历史?*

YesNo
If you have a history of a major illness, please specify the details: 如果有重大的疾病或受伤历史?, 请说明具体情况:*
For female: Are you pregnant? 如果您是女性, 请问您是否怀孕?*

YesNo
If you are pregnant female, please specify the details: 如果您是怀孕的女性, 请说明具体情况:*
Select any of the medical conditions below that you have had or currently have: 请标注您的身体是否有如下的情况:*

Abnormal bleeding 异常出血Diabetes 糖尿病Pneumonia 肺炎Anemia 贫血Dizziness 头晕Herpes 泡疹Prolonged Bleeding 长时间出血Arthritis 关节炎Epilepsy 癫痫High Blood Pressure 高血压Radiation/Chemotherapy 放射/化疗Asthma 哮喘Gastrointestinal Disorders 胃肠道疾病HIV / Aids HIV/爱滋病Rheumatic Fever 风湿热Bone Disorders 骨骼疾病Heart Problems 心脏疾病Kidney Problems 肾脏问题Tuberculosis 结核Congenital Heart Defect 先天性心脏病Heart Murmur 心脏杂音Nervous Disorders 神经紊乱Tumor or Cancer 肿瘤或癌症N/A 不适用Hepatitis 肝炎
Are there any medical conditions we have not discussed that you feel we should be aware of? 除了上述疾病之外，您的身体还有其他身体问题需要告知牙医吗？
*This is to certify that I, the undersigned, consent to the performing of the dental and oral procedures agreed to be necessary or advisable, including the use of general or local anesthetic as indicated and I will assume responsibility for fees associated with those procedures. In the presence of insurance, I authorize the handling of my insurance and exchange of information whether electronically or manually by Lotus Smile Dental office. Our office policy is 48 hours notice to cancel/change an appointment. $60 will be charged for late cancellation or no show.

Following is the Chinese Version:

以下是中文版本:

* 我尽所能提供我精确及完全的医学及牙医病史，并予授权我的医生给牙医诊所我的病史及所需医学报告。我授权牙医诊所医师及洗牙师给我本人及本人之未成年子女实施局部麻醉或处方药物。如果取消我会给诊所48小时的通知时间，如果没有及时通知我会承担$60的预约未到的费用。
Signature 您的签名*

Clear
Date 日期

MonthDayYear
Month-Date-Year 月-日-年
Should be Empty:

Welcome to Lotus Smile Dental

欢迎光临康嘉牙医诊所