New Patient Form

First Name

Are you a child or an adult?

Address

Email Address

Family Physician

If other, input name here:

Your Occupation

Spouse's Occupation

If a child, enter name of your parent/guardian

Relationship

Last Name

Date of Birth

Telephone Number (HOME)

Reason for today's visit

Family Physician's Telephone Number

If other, input telephone number here:

Employed by

Address (If different)

Telephone Number

Initial

Age

Telephone Number (WORK)

If other, input reason here:

Person Responsible for Account

If other, input address here:

Telephone Number of Employer

In case of emergency, notify:

Names of other family members who are patients at our office

Who referred you to this office?

Dental Insurance

Do you have a dental insurance?

S.I.N.

Employed by:

Secondary Insurance Co. (if any)

Name of Subscriber

Telephone Number

COVERAGE: Deductible $

COVERAGE: % Perio

Primary Insurance Co.

Name of Subscriber

Telephone Number

Policy #

Date of Birth

Cert. Number

COVERAGE: Basic

Policy #

Date of Birth

Cert. Number

S.I.N.

Employed by:

COVERAGE: Maximum a Year $

COVERAGE: % Endo

COVERAGE: % Major

Medical History

Are you presently under the care of a physician for any medical condition?

If yes, please specify

Physician's Name

Physician's Telephone Number

Are you taking or have you recently taken any prescription or non-prescription drugs?

If yes, please list them

Do you or have you ever had any heart or blood pressure problems (e.g. heart attack, heart murmur, mitral valve prolapse, angina, heart pacemaker, high or low blood pressure?)

Do you experience shortness of breath or chest pains when taking a walk or climbing stairs?

Have you ever been hospitalized for any serious illnesses or operations?

If yes, please specify

Have you ever had treatment for a tumor or growth (e.g. radiation, surgery, chemotherapy)?

Have you ever experienced an allergic or other bad reaction to a medication, injection, material or food of any kind (e.g. penicillin, aspirin or local anesthetics, "dental freezing", metals, latex)?)

Do you have a tendency to bruise easily or bleed for a prolonged period of time after being cut?

Do you have any conditions that could affect your immune systemt (e.g. AIDS, HIV positive, leukemia, etc.)?

Do you have or have you ever had jaundice, hepatitis (A, B or C), or liver disease?

Do you smoke, chew tobacco, or use a transdermal nicotine patch?

Do you have any hearing difficulties?

Do you have or have you ever had any blood disorders (e.g. anemia, sickle cell disease, etc.)?

Do you or does any member of your family have diabetes?

For women only: Are you taking birth control pills?

For women only: Are you pregnant or suspect you might be?

If so, when is the expected delivery date?

Is there anything the doctor should know about your medical history that has not been mentioned?

If yes, please specify

Dental History

How long since your last visit to the dentist?

Did you receive dental x-rays at that time?

Did you have your teeth cleaned?

Have you ever had local anaesthetic (freezing)?

Any complications? If yes, please specify:

Are you satisfied with the appearance of your teeth?

If not, please specify

How often do you brush?

How often do you floss?

Type of toothbrush

Have you ever received oral hygiene instruction in brushing?

Have you ever received oral hygiene instruction in flossing?

Have you ever received oral hygiene instruction in other areas?

If yes, please specify

Does food routinely catch between your teeth?

Please note any other dental concerns you have

Informed Consent / General Release

I, the undersigned, state that I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental, and oral surgery procedures and services

Patient (Parent, Guardian) Signature

Select File

If parent/guardian*, please print name

Date

Your form has been submitted. Thank you!

An error occurred. Try again later

New Patient Form

Dental Insurance

Medical History

Dental History

Informed Consent / General Release

KILDONAN PARK
DENTAL

Hours

New Patient Form

Dental Insurance

Medical History

Dental History

Informed Consent / General Release

KILDONAN PARK DENTAL

Hours

KILDONAN PARK
DENTAL