Patient Registration Form Patient InformationSalutationMr.Mrs.Ms.Dr.First NameLast NameDate of BirthRegistering for a child?YesNo OPTIONALPerson responsible for accountOPTIONALRegistering for a child?YesNoOPTIONALOther parental consent requiredYesNoOPTIONALMother's nameOPTIONALBusiness TelOPTIONALFather's nameOPTIONALBusiness TelContact InformationEmailHome PhoneCell PhoneWork PhoneAddressStreet AddressProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonCityPostal CodeIn case of emergency, please notify:NameRelationHome PhoneCell PhoneWork PhoneContact OptionsI prefer appointment reminders byPhoneSMS (TEXT)EmailWhom 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 InformationYes, insurance applies to meNo, insurance does not apply to mePlease complete the following if you have dental insuranceName of insured/subscriberDate of BirthPatient's relationship to subscriberSelfSpouseChildPlace of EmploymentInsurance CompanyPolicy/Group #Certificate/ID #I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminationsMedical HistoryThe 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/MaybeWhen was your last medical checkup?Has there been any change in your general health in the past year?YesNoNot Sure/Maybe Please SpecifyAre 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 datesDo you have or have you ever had asthma?YesNoNot Sure/MaybeDo you have or have you ever had any heart or blood pressure problems?YesNoNot Sure/MaybeDo 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/MaybeDo you have a prosthetic or artificial joint?YesNoNot Sure/MaybeDo you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?YesNoNot Sure/Maybe OPTIONALPlease SpecifyHave you ever had hepatitis, jaundice, or liver disease?YesNoNot Sure/MaybeDo you have a bleeding problem or bleeding disorder?YesNoNot Sure/Maybe OPTIONALPlease SpecifyHave you ever been hospitalized for any illnesses or operations?YesNoNot Sure/Maybe OPTIONALPlease SpecifyDo 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 DiseaseAre 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/MaybeAre you nervous during dental treatment?YesNoNot Sure/MaybeFor women only: Are you pregnant or breastfeeding?YesNoNot Sure/Maybe OPTIONALWhat is your expected delivery date?Dental HistoryDo 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 meIs there anything about the appearance of your teeth that you would like to change?Have you ever whitened (bleached) your teeth?YesNoNot Sure/MaybeDo 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.