Patient Registration Form Patient Information SalutationMr.Mrs.Ms.Dr. First Name Last Name Date of Birth Registering for a child?YesNo OPTIONALPerson responsible for account OPTIONALRegistering for a child?YesNo OPTIONALOther parental consent requiredYesNo OPTIONALMother's name OPTIONALBusiness Tel OPTIONALFather's name OPTIONALBusiness Tel Contact Information Email Home Phone Cell Phone Work Phone Address Street Address ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon City Postal Code In case of emergency, please notify: Name Relation Home Phone Cell Phone Work Phone Contact Options I prefer appointment reminders byPhoneSMS (TEXT)Email Whom may we thank for referring you? Are any other members of your family patients at our practice?YesNo OPTIONALAre any other members of your family patients at our practice? Insurance Information Yes, insurance applies to meNo, insurance does not apply to me Please complete the following if you have dental insurance Name of insured/subscriber Date of Birth Patient's relationship to subscriberSelfSpouseChild Place of Employment Insurance Company Policy/Group # Certificate/ID # I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form. Are you being treated for any medical condition at the present or any time within the past year?YesNoNot Sure/Maybe When was your last medical checkup? Has there been any change in your general health in the past year?YesNoNot Sure/Maybe Please Specify Are you taking any prescription, non-prescription medications, or herbal supplements?YesNoNot Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment. Do you have any allergies?YesNoNot Sure/Maybe SelectMedicationsLatex,Rubber ProductsOther (e.g hayfever, foods, etc) Have you ever had a peculiar or adverse reaction to any medicines or injections?YesNoNot Sure/Maybe OPTIONALPlease list below with approximate dates Do you have or have you ever had asthma?YesNoNot Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?YesNoNot Sure/Maybe Do you have or have you 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?YesNoNot Sure/Maybe Do you have a prosthetic or artificial joint?YesNoNot Sure/Maybe Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?YesNoNot Sure/Maybe OPTIONALPlease Specify Have you ever had hepatitis, jaundice, or liver disease?YesNoNot Sure/Maybe Do you have a bleeding problem or bleeding disorder?YesNoNot Sure/Maybe OPTIONALPlease Specify Have you ever been hospitalized for any illnesses or operations?YesNoNot Sure/Maybe OPTIONALPlease Specify Do you have, or have ever had any of the following? Please checkChest pain/anginaOsteoporosis MedicationsMitral Valve ProlapseShortness of BreathRheumatic FeverHeart AttackStrokeCancerPacemakerLung DiseaseHeart MurmurArthritisSteroid TherapyDiabetesTuberculosisDrug/Alcohol DependencySeizuresThyroid DiseaseStomach UlcersKidney Disease Are there any conditions/diseases not listed that you have or have had?YesNoNot Sure/Maybe OPTIONALIf yes, please specify: Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?YesNoNot Sure/Maybe OPTIONALIf yes, please specify: Do you smoke or chew tobacco products?YesNoNot Sure/Maybe Are you nervous during dental treatment?YesNoNot Sure/Maybe For women only: Are you pregnant or breastfeeding?YesNoNot Sure/Maybe OPTIONALWhat is your expected delivery date? Dental History Do you have any specific dental concerns? Please list: When was your last dental appointment? How often do you see the dentist?Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering me Is there anything about the appearance of your teeth that you would like to change? Have you ever whitened (bleached) your teeth?YesNoNot Sure/Maybe Do you feel uncomfortable or self-conscious about the appearance of your teeth? Have you been disappointed with the appearance of previous dental work? I agree to receive emails with related information and updates.
