New Patient Form

    PERSONAL HISTORY & INFORMATION

    Patient's Name


    Pronouns
    He/HimShe/HerThey/Them
    Date of Birth



    Home Address
    City Name
    Post Code



    Home Phone No
    Work Phone No
    Email Address


    Cell No
    Patient Employed By


    occuoation
    Emergency Contact Form


    Emergency Contact Form
    Emergency Contact Form


    Previous Dentist
    Phone No


    Whom may we thank for referring you?





    INSURANCE INFORMATION

    Name of insurance Company
    Insured's Name


    Employer
    Insured's Birthdate


    Group/Contract No
    Relationship to insured


    Insured's ID No

    *Payment is due at the time of the appointment unless other arrangements have been made*


    MEDICAL HISTORY

    1. Do you have current medical problem? Please check

    If yes, what?



    2. Have you ever had a serious injury or major operation in last 5 years?

    If yes, what?



    3. Are you presently being treated by a physician?





    4. Are you taking any medication, pill, drugs, or medicine?

    If yes, what?



    5. Do you smoke?




    MEDICAL ALERT

    The data contained in this confidential questionnaire is essential to render you our best professional care.

    We appreciate your cooperation in filling out this questionnaire carefully so that we will have accurate records.

    1. Do you now have or have you ever had any of the following? Please check
    Heart Trouble or StrokeHigh or Low Blood PressureTuberculosisDiabetesHepatitis, Jaundice, Liver DiseaseChest Pains, Shortness of BreathAsthma or AllergieArthritisDrug Allergies or ReactionsEpilepsy or SeizuresRheumatic FeverKidney DiseaseBleeding problems or DisordersSexually Transmitted DiseasesFrequent HeadachesCancerArtificial Joint Replacement SAVHIV






    2. Have you ever had an allergic reaction or side effect from any of the following? Please check:

    Other (specify)




    3. Is there anything else we should know about your health?

    Describe





    4. Are you pregnant?

    If so, due date





    DENTAL HISTORY

    1. What dental condition concerns you at present?
    Describe




    2. When was your last visit to a dentist?
    Describe




    3.When was your last cleaning?
    Describe




    4. Do you have any sore, aching, or sensitive teeth?


    5. Do your gums bleed when brushing your teeth?




    6. Are you presently wearing partial or complete dentures?




    7. Do you grind or clench your jaws or teeth during the day or night?




    8. Have you ever had any complications with local anaesthetic (freezing)?




    9. Is there anything you would like to be done to improve the appearance of your teeth?




    10. Have you ever had orthodontic treatment (braces, etc.)?




    11. Have you ever visited a periodontist (gum specialist)?





    CONSENT

    Due to the precise nature of appointment scheduling, we charge the fee suggested by the B.C. Dental. Association for appointments missed or cancelled without 48 hours notice.





    Signature Here



    AESTHETIC DENTISTRY

    There are many advances in aesthetic dentistry.

    READ MORE