New Patient Information
In an effort to serve you better, we ask that you complete the following. We will be glad to assist you.
Medical Alert
Patient Information:
A Parent or Guardian will be responsible for decisions on my treatment:
Yes
No
Name:
First Name
Initial
Last Name
Address:
Street
Apt
/ Unit
City
Province
Postal Code
Date of Birth:
Gender:
Male
Female
Contact:
Home Phone
Cell
Work Phone
Email
Emergency Contact
Contact's Phone
Family Doctor
Dr.'s Phone
Financial Information:
Person responsible for financial matters:
Self
Spouse
Parent/Guardian
Other
Primary Insurance:
Ins. Company
Employer/ Policy Holder
Policy #
Certificate #
Max Coverage
% Coverage for:
Basic
Maj. Restorative
Orthodontics
Insurance Details:
Secondary Insurance:
Ins. Company
Employer/ Policy Holder
Policy #
Certificate #
Max Coverage
% Coverage for:
Basic
Maj. Restorative
Orthodontics
Insurance Details:
Dental History:
1. What is the reason for your visit?
Emergency
Examination
Other
Other
2. How frequently do you visit a dentist?
3-6 months
Annually
Other
Other
3. When was your last dental visit?
Last X-ray?
4. How often do you brush per day?
Floss?
Use Antibacterial rinse?
5. Are your teeth sensitive to:
Cold
Heat
Sweets
Other
Other
6. Do your gums bleed when:
Brushing
Flossing
Never
Other
Other
7. Do your jaws crack, pop or grate what you open widely?
Yes
No
8. Do you regularly grind or clench your teeth?
Yes
No
9. Have you ever had any problems with previous dental treatments? Specify:
10. Have you ever had any of the following?
Bridgework
Crowns or Caps
Full or Partial Dentures
Orthodontic (braces)
Periodontal (Gum Surgery)
Root Canal