1Patient Information2Insurance Information3Medical History4Dental History Patient InformationHow did you hear about our office? Name* First Last Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Prefer Not to Answer Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Cell PhoneWork PhoneHome PhoneEmail* Drivers License # Emergency Contact Emergency Contact PhoneFamily Doctor Family Doctor Phone Insurance InformationPolicy Holder BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insurance Company Employer Policy # Cert/ID # Basic (A) %Major (B) %Yearly MaxI, the undersigned, understand that the information contained in themedical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care providers as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine the necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.Signature*Please Select One* Self Parent Gaurdian Medical History(This information is necessary for your dental care and will remain confidential.)Are you currently under the care of a physician due to a specific medical condition? Yes No Are you taking any prescription or non-prescription medications? Yes No Please list the medication and reason for the medication.MedicationReason Are you allergic to or have had an adverse reaction to any medications? Yes No Please select the medication that you are allergic to or had a reaction to Aspirin Barbiturates Codeine Erythromycin Local Anesthetic Penicillin Sulfa Valium Other Please state any other medications you are allergic to Have you ever been warned against taking any other medications? Yes No Which? Do you suffer from any allergies (hay fever, latex, etc.)? Yes No Which? Do you bruise easily or have prolonged bleeding? Yes No Do you smoke or use tobacco products? Yes No How much per day? Women: Are you pregnant? Yes No What is your due date?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have or have you ever had any of the following? Artificial Joints Artificial Heart Valve Blood Disorder Cancer Diabetes Emphysema Heart Disease Heart Surgery Heart Murmur Hepatitis A B C High Blood Pressure HIV Positive (AIDS) Kidney Disease Low Blood Pressure Liver Disease Lung Disease STD Migraines Radiation/Chemotherapy TX Rheumatic Fever Mental/Nervous Disorder Stroke Thyroid Disease Do you have any disease, condition, or problem not listed? Dental HistoryWhat is the reason for today’s visit? How frequently do you see a dentist? 3 - 6 Months Annually When was your last dental visit? When were your last dental x-rays? How often do you brush your teeth? How often do you floss your teeth? Are your teeth sensitive to Cold Sweets Heat Do your gums bleed when Brushing Flossing Never Do you grind or clench your teeth? Are you satisfied with the way your teeth feel? Have you ever had any problems with previous dental treatments? What, if anything, would you change about your smile? CommentsThis field is for validation purposes and should be left unchanged. Δ
