Patient Registration Form Patient Information *All fields requiredSalutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* MM slash DD slash YYYY Age*Gender* Male Female Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Mobile Phone*Home Phone*Mobile Phone*Work Phone*How did you hear about us?*Preferred method of contact?* Phone SMS Email Adult Patient?* Yes No Occupation*Employer*Occupation*Child Patient?* Yes No Mother's name*Mother's Phone*Father’s name*Father's Phone*Person responsible for account*Name of Family Doctor*Phone*In case of emergency, please notify:Name*Relationship*Phone*Medical Information1. Are you being treated for any medical condition at the present or have you been treated within the past year?* Yes No If yes, please explain*2. When was your last medical check-up?* MM slash DD slash YYYY 3. Has there been any change in your general health in the past year?* Yes No Please Specify*4. Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No If yes, please list medications and dosage:*5. Do you have any allergies?* Yes No If yes, please explain*6. Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No If yes, please explain*7. Do you have or ever had asthma?* Yes No 8. Do you have or ever had any heart or blood pressure problems?* Yes No 9. Do you have or ever had an artificial heart valve, infection of the heart (i.e.infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No If yes, please explain*10. Do you have a prosthetic or artificial joint?* Yes No 11. Do you have any conditions which may affect your immune system? (i.e. Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy)* Yes No 12. Have you ever had hepatitis, jaundice, or liver disease?* Yes No 13. Do you have a bleeding problem or bleeding disorder?* Yes No 14. Have you ever been hospitalized for any illnesses or operations?* Yes No Please specify*15. Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Shortness of breath Heart Attack Rheumatic Fever Mitral Valve Prolapse heart murmur Pacemaker Lung Disease tuberculosis stroke Steroid Therapy Diabetes stomach ulcers arthritis Seizures (epilepsy) kidney disease Thyroid Disease cancer osteoporosis medications drug/alcohol dependency None of the Above 16. Are there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe If yes, please explain*17. Are there any diseases/medical problems that run in your family (eg-diabetes, cancer, heart disease)?* Yes No 18. Do you smoke or chew tobacco products?* Yes No 19. Are you nervous during dental treatment?* Yes No 20. For women only: Are you pregnant or breastfeeding?* Yes No If yes, how many months?*Nursing*Taking Birth Control Pills*Dental History1. When was your last dental visit?* MM slash DD slash YYYY Reason*2. How often do you visit the dentist?*3. How often do you brush your teeth?*4. How often do you floss your teeth?*5. Do any of the following cause tooth discomfort?* Cold Hot Sweets Chewing 6. Are you having any problems that require immediate attention?* Yes No If yes, please explain*7. Do your gums bleed when you brush your teeth?* Yes No 8. Have you noticed any loose teeth?* Yes No 9. Do you clench or grind your teeth?* Yes No 10. Have you been diagnosed with sleep apnea?* Yes No 11. Have you ever had orthodontic treatment (Braces or Invisalign?)* Yes No 12. Are you interested in straightening your teeth?* Yes No 13. Are you interested in whitening?* Yes No 14. Are you interested in crowns or implants?* Yes No 15. Have you ever had any complications or issues with previous dental treatment?*16. Please list anything else not mentioned above regarding your past dental history.*Insurance InformationInsurance Coverage:* Yes No Policy holder's name:*Policy holder's date of birth:*Your insurance company/carrier:*Group or policy number:*I.D./Certificate No.:*Employer:*Secondary Insurance (If Applicable):* Yes No Second Policy holder's name:*Second Policy holder's date of birth:*Second insurance company/carrier:*Second Group or policy number:*Second I.D./Certificate No.:*Second Employer:*Cancellations & Missed Appointments Your appointment time has been reserved exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient. Appointments that are cancelled with less than 48 hours notice and missed appointments are subject to $50.00 fee. This fee will be due in full prior to your next scheduled appointment.Cancellations & Missed Appointments Your appointment time has been reserved exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient. Appointments that are cancelled with less than 48 hours notice and missed appointments are subject to $50.00 fee. This fee will be due in full prior to your next scheduled appointment.General Release I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform all diagnostic procedures including and not limited to x-rays and photographs, as may be required to determine necessary treatment, and to perform necessary or advisable treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that my dental insurance may not cover entirely the total fee of services provided. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.First & Last Name*Email Address* Signature* I agree to receive emails with related information and updates. EmailThis field is for validation purposes and should be left unchanged.
