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PATIENT INFORMATION
The data on this confidential form is essential if we are to render the best professional care. Please feel free to ask receptionist for help in completing this form.
Name
Date of Birth
date_range
Cell Phone
Address
Prov.
City/Town
Postal Code
Home phone
Employer/School
Occupation
Referred by
Marital Status:
In case of Emergency (Name):
Relationship:
Phone:
Name of Insurance Company
Plan/Group number
Certificate number
Person Responsible for Account
Do you have a secondary insurance?
If yes, name of insurance company, plan #, certificate #, and person responsible for account
DENTAL HISTORY
Previous Dentist
Address
Phone
Date of last visit
1. Are you having discomfort at this time?
2. Have you been under regular care by a dentist?
3. Do your gums feel tender or swollen?
4. Are you aware of any lump or swelling in your mouth?
5. Have you ever had a problem with local or general anesthetic?
6. Is any part of your mouth sensitive to temperature, pressure or sweets?
7. Do you awaken with pain in your teeth or jaws?
8. Do you ever get cold sores or fever blisters?
9. Do you currently experience?
10. Are you tense during dental visit?
MEDICAL HISTORY
Physician
Health Card #
Expiry Date
1. Are you currently under medical treatment?
Specify:
2. Are you taking any medication?
Specify:
3. Do you have drug allergies? (Aspirin, Codeine, Penicillin, Dental Anaesthetic…)
Specify:
4. Have you ever been treated for AIDS – related complex?
Specify:
5. Do you use Tobacco? How much?
Specify:
6. Have you ever had any major operations? What kinds?
Specify:
7. Do you bruise or bleed easily?
Specify:
8. Have you recently had a communicable disease?
Specify:
9. Are you pregnant?
Specify:
10. Have you ever had or been treated for?
11. Is there anything else we should know about your health? Please specify:
12. Do you have osteoporosis?
Medication
This is to certify that I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable including the use of local anesthetic and/or relative analgesia as indicated, and I will assume responsibility for fees associated with those procedures.
Signature
(Sign Here)
Clear Signature
Date
date_range
Reviewed by treating Dentist:
Date
date_range
All accounts payable when services are rendered. Interest will be charged on overdue accounts.
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