New Patient Form

Contact Information

Name

Date of Birth

Address

City

Povince

Postal Code

How would like to be contacted for appointment reminders?

Phone

In case of emergency, we should notify: Name, Relationship and Phone

Name of Family Doctor?

Doctor's Phone

Insurance Information

Company #1 (optional)

Policy Group # (optional)

ID # (optional)

Policy Holders' Name (optional)

Policy Holders' Employer (optional)

Policy Holders' Birth Date (optional)

Company #2 (optional)

Policy Group # (optional)

ID # (optional)

Policy Holders' Name (optional)

Policy Holders' Employer (optional)

Policy Holders' Birth Date (optional)

Client Dental History

Reason for your visit?

Are you having a dental pain or discomfort?

Do your gums bleed when flossing or brushing?

Do you clench or grind your teeth?

How often do you brush your teeth?

Floss?

Do you use any additional tools to clean your teeth?

Have you ever had: Dental abscess?

Loose teeth?

Swollen gums?

Are your teeth sensitive to hot, cold or sweets?

Do you have any problems with your jaw joint?

Client Medical History

1. Are you being treated for any medical condition at the present time or have your been treated within the past year? If yes, please explain:

2. When was your last medical check-up?

Are you taking any medications? Please list below:

Yes

4. Have you experienced an allergic reaction to any of the following? Please select if yes (optional)

Aspirin

Tetracyclines

Dental Anesthetics

Penicillin

Aspirin

Latex

Erythromycin

Codeine

Other (optional)

Please provide details if you selected any of the above (optional)

Other (optional)

Please provide details if you selected any of the above (optional)

6. Do you bleed for an abnormally long time if you cut yourself?

Yes

7. Do you smoke?

Yes

If YES, how many per day (optional)

Have you ever had any peculiar or adverse reaction to medication or injections?

Yes

If YES, please explain: (optional)

Do you ever had a heart valve replacement, infection of your heart (infective endocarditis), a heart condition from birth (congenital heart disease) or a heart transplant?

Yes

If YES, please explain: (optional)

10. Do you have a prosthetic or artificial joint?

Yes

If YES, details: (optional)

11. Have you been advised by your doctor to take antibiotics before dental treatment?

Yes

If YES, details: (optional)

12. Have you been hospitalized for any illness or operations? If YES, please explain

Yes

If YES, details: (optional)

13. Is there any other medical information you think we should know? (optional)

14. Are you pregnant (Women Only)? If YES, what is the expected delivery date? (optional)

Yes

If YES, details: (optional)

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. I understand
that providing incorrect information can be dangerous to my health. I authorize and request my insurance
company to pay directly to the dentist. I understand that my dental insurance carrier may pay less than the
actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my
dependents. I understand that 48 hours notice is required to cancel any appointments an that there is a
charge for missed appointments.

Digital Signature

Contact Information

Insurance Information

Client Dental History

Client Medical History

Authorization and Release

office address

Contact Information

office hours

contact us

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Open 6 Days a Week

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