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PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Preferred Phone

Email

Contact Method

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 #

PATIENT INFORMATION

Personal Health Number

DENTAL INFORMATION

Have you ever seen/had any of the following treatment(s) before?

Periodontal Treatement? (treatment of the gums)

Yes

No

If yes, please explain:

Orthodontic Treatment? (to straighten or realign teeth)

Yes

No

If yes, who provided the treatment, when did you start and for how long?

Oral Surgery? (surgery in or about the mouth/jaw joint or implant surgery)

Yes

No

If yes, who performed the surgery and when?

Are you currently being followed up by a dental specialist?

Yes

No

DENTAL INFORMATION

Have you ever experienced any of the following?

MEDICAL INFORMATION

Are you currently seeing a Family Physician?

Yes

No

If yes, please enter Name, Phone Number:

Date of your last Physical Exam

Have you ever had a serious head or neck injury?

Yes

No

Have you recently (in the last two years) been hospitalized or had a major operation?

Yes

No

Please Explain.

WOMEN ONLY

Are you pregnant or suspect you may be?

Yes

No

If yes, what is the expected delivery date?

Are you taking any birth control pills?

Yes

No

INDICATE ANY PRESENT OR PAST CONDITIONS

Please go over the following section and indicate which of the following you have or have had.&edsp;&edsp;If you need to add any further information please enter at the end

Additional information that may not have been listed above

Do you currently have, or have you had in the past, any disease, condition or problem not listed above?

Yes

No

If yes, please specify:

Do you wish to speak privately about any problem or medical condition?

Yes

No

CHILDREN ONLY

Recent Conditions (Please indicate Date)

INSURANCE

Has your dental insurance changed, since your last visit?

Yes

No

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance