New Patient - Complete MED + NP Form
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
Information
We would like to send you email and text communication which may include appointment confirmation, newsletters,up coming events, and important notifications. Please indicate if you would like to receive future emails and text communications from us.
Yes
No
Family Physician
Family Physician Phone
Name of Medical Specialist and speciality
Medical Specialist 1 Phone
Name of Medical Specialist and speciality
Medical Specialist 2 Phone
Parent/Guardian/Caregiver Information
Name 1 (Surname, Given)
Relation
Address (if different from above)
Phone number
Occupation
Work number
Name 2 (Surname, Given)
Relation
Address (if different from above)
Phone number
Occupation
Work number
Please list any other persons who may have access to this file (name, relation)
How did you hear about us?
Friend
Staff member at our office
Family member
Colleague
Patient at our office
Refferal from health professional
Website/Internet
Advertisement
Sign/Office in person
Other
Office Policy: Your appointment time will be reserved for you. If you are unable o keep the appointment, we will require 24 hours notice, otherwise it may be necessary to charge for time lost
Signature of
Patient
Parent
Guardian
Caregiver
Date
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Dental History
Reason for visit
Do you have a current dental problem that needs to be addressed?
Yes
No
Have you been visiting the dentist regulary?
Yes
No
Last Dental visit
Last cleaning visit
Last X-rays
How often do you brush your teeth?
How often to you floss your teeth?
Do your gums bleed regulary?
Are your teeth sensitive to:
Hot
Cold
Biting
Sweets
Sour
N/A
Do you feel any pain in your teeth?
Yes
No
Have you had any head, neck, or jaw injuries/surery?
Yes
No
Do you have dry mouth or difficulty swallowing?
Yes
No
Do you snore or have sleep apnea?
Yes
No
Does your jaw crack, click or pop when opening widely?
Yes
No
Do you grind or clench your teeth during the day or night?
Yes
No
Have your ever experienced any growths, lumps or sore spots in your mouth?
Yes
No
Have you noticed any loosening/movement of your teeth?
Yes
No
Have you had periodontal (gum) treatment?
Yes
No
Have you had orthodontic (braces) treatment?
Yes
No
Have you had previous problems with dental treatment?
Yes
No
Are you satisfied with the appearance of your teeth?
Yes
No
Are you nervous/anxious/fearful during dental treatment?
Yes
No
Please list any other information that you feel we should have to provide you with th bet possible dental care:
Signature of
Patient
Parent
Guardian
Caregiver
Date
Reviewed by Dentist
Date
Medical History
Do you have any health problems?
Yes
No
If yes, please provide details:
Are you currently being treated for any medical conditions or have been treated in the past year?
Yes
No
If yes, please explain:
When was the last time you have had a medical examination
Were any problems identifed? If so, please explain:
Have you even been hospitalized for any illness or surgeries?
Yes
No
If yes, please provide details:
Are you taking any medications, non-prescription drugs, homeopathic or herbal supplements or hormone of any kind?
Yes
No
If yes, please list and provide reasons for taking?
Do you have any allergies or adverse reactions to medications, products, latex, food and/or environmental
Yes
No
If yes, please list:
Do you have or had you ever had a replacement or a repair of a heart valve, an infection of the heart (i.e. infective edocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Yes
No
If yes, please explain:
Have you been advised to take pre-medication (e.g. antibiotics) prior to dental treatment?
Yes
No
If yes, please explain:
Do you have a prostetic or artificial joint?
Yes
No
If yes, please provide details:
Do you have any conditions of have undergone therapies that could affect your immune systems? (Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)
Yes
No
If yes, please explain:
Have you ever had hepatitis, jaundice, liver disease, or gastrointestinal disorders?
Yes
No
If yes, please explain:
Do you have a bleeding problem, bleeding disorder, bruising tendency, or have had a blood transfusion?
Yes
No
If yes, please explain:
Do you have any or have you ever had any of the following (check all that apply):
Fainting/Dizzy spells
Eating disorder
Stroke/TIA
Rheumatic fever
Mitral valve prolapes
Heart murmur
Asthma or emphysema
Pacemaker
Lung disease
Tuberculosis
Cancer
Steriod therapy
Diabetes
Stomach ulcers
High Blood pressure
Low Blood pressure
Arthritis/Rheumatism
Seizures/Epilepsy
Kidney disease
Thyroid disease
Hyper/Hypoglycemia
Mental or Nervous disorder
Circulatory problems
Blood transfusion
Other communicable disease/ Transmissable infection
Chest pain/Angina/Heart attack
Drug/Alcohol/Cannabis use or dependency
Shortness of breath
Osteoporosis
Are there any conditions or diseases not listed above that you have or have had?
Yes
No
If yes, please explain:
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease, etc)
Yes
No
If yes, please explain:
Do you smoke, vape, use e-cigarettes or chew tobacco products?
Yes
No
Have you recently travelled to areas where endemic diseases are present?
Yes
No
Have you recently experienced any new symptoms such as cough, fever, chills, vomiting, diarrhea, rash or other illnesss since recent travel or otherwise?
Yes
No
Have you had a recent exposure to a communicable infectious disease? (e.g. measles, chicken pox or tuberculosis)
Yes
No
Have you recently received antimicrobial therapy?
Yes
No
If so, for what reason:
Is there any additional information related to your health that has not been addressed above?
Yes
No
Signature
Patient
Parent
Guardian
Caregiver
Date
Reviewed by Dentist
Date
Women ONLY
Are you pregnant?
Yes
No
If yes, what is the expected delivery date:
Are you breast feeding?
Yes
No
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