Patient Registration Form

Patient Information

SalutationFirst NameLast NameDate of BirthRegistering for a child?

YesNo

Contact Information

EmailCell PhoneHome Phone
Work Phone

Address

Street Address
ProvinceCityPostal Code

In case of emergency, please notify:

NameRelation
Cell Phone
Home Phone
Work Phone

Contact Options

I prefer appointment reminders by

PhoneSMS (Text)Email

Whom may we thank for referring you?Are any other members of your family patients at our practice?

YesNo

Insurance Information

Yes, insurance applies to meNo, insurance does not apply to me

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

Are you taking any prescription, non-prescription medications, or herbal supplements?

YesNoNot Sure/Maybe

Do you have any allergies?

YesNoNot Sure/Maybe

Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNoNot Sure/Maybe

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

Have you ever had hepatitis, jaundice, or liver disease?

YesNoNot Sure/Maybe

Do you have a bleeding problem or bleeding disorder?

YesNoNot Sure/Maybe

Have you ever been hospitalized for any illnesses or operations?

YesNoNot Sure/Maybe

Do you have, or have ever had any of the following? Please checkAre there any conditions/diseases not listed that you have or have had?

YesNoNot Sure/Maybe

Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?

YesNoNot Sure/Maybe

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

How do you rate the quality of your sleep?

ExcellentModeratePoor

Do you snore or think you breathe through your mouth?

YesNoNot Sure/Maybe

Do you feel refreshed in the morning?

YesNoNot Sure/Maybe

Dental History

Do you have any specific dental concerns? Please list:When was your last dental appointment?How often do you see the dentist?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.

Thank you! Your submission has been received!

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