New Patient Form Leave this field blank Contact Information Name Date of Birth Address City Povince Postal Code Email How would like to be contacted for appointment reminders? Phone Email 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 No 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) 5. Have you ever had any of the following illnesses? Please select if yes (optional) Hepatitis Heart Attack Seizures HIV/AIDS Stroke Pace Maker Rheumatic Fever High Blood Pressure Arthritis Thyroid Problems Epilepsy Lung Disease Ulcers Diabetes Kidney Disease Asthma 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 No 7. Do you smoke? Yes No If YES, how many per day (optional) Have you ever had any peculiar or adverse reaction to medication or injections? Yes No 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 No If YES, please explain: (optional) 10. Do you have a prosthetic or artificial joint? Yes No If YES, details: (optional) 11. Have you been advised by your doctor to take antibiotics before dental treatment? Yes No If YES, details: (optional) 12. Have you been hospitalized for any illness or operations? If YES, please explain Yes No 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 No 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 understandthat providing incorrect information can be dangerous to my health. I authorize and request my insurancecompany to pay directly to the dentist. I understand that my dental insurance carrier may pay less than theactual bill for services. I agree to be responsible for payment of all services rendered on my behalf or mydependents. I understand that 48 hours notice is required to cancel any appointments an that there is acharge for missed appointments. Digital Signature Start drawing Clear Done Start over Submit
