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Patient Forms

Patient Forms2019-03-18T11:34:47+00:00

Patient Registration Form

Before coming in feel free to download the patient registration form OR fill out the form below.

Download Form

Dental/Medical History Form

Personal Information
Salutation
First Name*
Last Name*
Initials
Gender
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Address Information
Address*
City*
Province*
Postal Code*
Contact Information
Residential Phone*
Cell Phone*
Work Phone
Email
Preffered Method of Contact
Emergency Contact Name*
Emergency Contact Phone*
Insurance Carrier
Primary Insurance
Name of Insured
Date
Date Format: MM slash DD slash YYYY
Employer
Insurance Provider
Group Policy #
Division
ID / Certificate #
SIN #
Secondary Insurance
Name of Insured*
Date
Date Format: MM slash DD slash YYYY
Employer*
Insurance Provider*
Group Policy #*
Division
ID / Certificate #
SIN #
Medical History
Are you presently under the care of a Physician?
- Yes
- No
Have you been hospitalized in the past 2 years?
Are you taking any drugs or medications? Click the + button to add a new medication.
Have you ever had any allergies to any medication?
- Yes
- No
Which Medications?
Have you ever been warned against using any medication?
- Yes
- No
Which Medications?
Do you suffer from any non-drug related allergies?
- Yes
- No
List any non-drug related allergies
Are you allergic to latex?
- Yes
- No
Do you bruise easily or have prolonged bleeding?
- Yes
- No
Do you smoke?
- Yes
- No
How many per day?
Have you ever had chest pains?
- Yes
- No
Do you have shortness of breath?
- Yes
- No
Have you ever been advised to take antibiotics before a Dental treatment?
- Yes
- No
Women
Are you pregnant?
- Yes
- No
What is the due date:
Date Format: MM slash DD slash YYYY
Have you reached Menopause?
- Yes
- No
Are you using Birth Control?
- Yes
- No
Children
Chicken Pox
- Yes
- No
When
Measles
- Yes
- No
When
Mumps
- Yes
- No
When
Strep throat
- Yes
- No
When
Tonsillitis
- Yes
- No
When
Do you have, or have you ever had, any of the following?
- A.I.D.S
- Anemia
- Angina
- Anorexia Nervosa
- Arthritis/Rheumatism
- Artificial Heart Valve
- Artificial joint(s)
- Asthma
- Blood disorder
- Bronchitis
- Bulimia
- Cancer
- Circulation problems
- Congenital heart lesions
- Cortisone/steroid treatment
- Diabetes
- Drug/alcohol dependence
- Emphysema
- Epilepsy/Seizures
- Glandular disorders
- Glaucoma
- Head/neck injuries
- Heart disease/Attack
- Heart murmur
- Heart pacemaker/surgery
- Heart rhythm disorder
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Herpes
- High/Low Blood pressure
- H.I.V Positive
- Hodgkin’s disease
- Hyper/Hypo Glycemia
- Hypertension
- Jaundice
- Kidney disease
- Liver disease
- Leukemia
- Lung disease
- Malignant hypothermia
- Mental/nervous disorder
- Migraine headaches
- Mitral valve prolapse
- Organ transplant/implant
- Psychiatric treatment
- Radiation/chemotherapy
- Recurring headaches
- Rheumatic or scarlet fever
- Sickle cell disease
- Sinus trouble
- Stomach/intestinal probs
- Stroke
- Thyroid disease
- Tuberculosis
- Venereal disease
Dental History
What is your reason for today's visit?
How frequently do you see a dentist?
When was your last dental visit?
Date Format: MM slash DD slash YYYY
Who was your dentist?
How often do you brush per day?
How often do you floss per day?
Are your teeth sensitive to
- Cold
- Sweets
- Heat
- Other
Do your gums bleed when:
- Brushing
- Flossing
- Never
Do your gums feel swollen or tender?
- Yes
- No
Do you have bad breath or a bad taste in your mouth?
- Yes
- No
Do your jaws crack, pop or grate when you open widely?
- Yes
- No
Do you experience recurring headaches or migraines?
- Yes
- No
Do you grind or clench your teeth?
- Yes
- No
Does food ever catch between your teeth?
- Yes
- No
Have you ever had local anesthetic? (freezing)
- Yes
- No
Any complications? Specify
Have you ever had any problems with previous dental treatment?
- Yes
- No
Specify
Have you ever had any of the following?
- Bridgework
- Crowns/Caps
- Full/Partial Dentures
- Orthodontic (braces)
- Periodontal (gums)
- Root Canal
Do you snore?
- Yes
- No
Any family history of Sleep apnea?
- Yes
- No
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 to the best of my knowledge 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 authorize electronic submission of benefits claims on my behalf to my insurance carrier. Missed appointments or cancellations with less than 2 business days notice will be billed $50
Form Verification*
- I verify the information provided above is correct.
Comments
This field is for validation purposes and should be left unchanged.