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North York Family Dentist Office North York Family Dentist Office

New Patient Information Form

We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.

In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.

PATIENT INFORMATION

A parent or guardian will be responsible for decisions on my treatment: Yes   |   No

Title: 

Your Name:

Pronounciation:   Preferred to be called:

Date of Birth:

Address:

Contact Information

Preferred Contact Method 

Who may we thank for referring you to this office? 

Emergency Contact:   Phone Number: 

Relationship:  Family Doctor:

Referring Doctor/Medical Specialist:  Phone Number: 

Person responsible for this account:

Self    Spouse    Parent    Legal Guardian    Other:

Name   Phone Number: 

Relationship:

Address:

   

 

INSURANCE INFORMATION

Methods of Payment

Cash    Debit    VISA    Mastercard    Insurance

Person Responsible for Payment

Self    Spouse    Parent/Guardian    Other   

Do you have Dental Insurance?* Yes   |   No
If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Information

Policy Holder's Name:

Insurance Provider:      

Insurance Year End: (usually Dec. 31)  

% Coverage For:  

Secondary Insurance Information (if applicable)

Policy Holder's Name:

Secondary Insurance Information (if applicable)

Policy Holder's Name:

Insurance Provider:      

Insurance Year End: (usually Dec. 31)  

% Coverage For:  

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 fill in the entire form

Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?*

If yes, please specify:

When was your last medical checkup?

Has there been any change in your general health in the past year? If yes, please explain.

If yes, please explain:

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

If yes, please list:

Do you suffer from any allergies (hay fever, latex, etc)?

If yes, to what?:

Allergies: Have you ever had a reaction to any of the following?*

Penicillin Sulfonamide Asprin Barbiturates (sleeping pills) Codeine Darvon Local Anesthetic (Freezing) General Anesthetic No Drug Allergies other (please specifiy below)

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

If yes, please specify:

Do you have or have you ever had asthma?

Do you have or have you ever had any heart or blood pressure problems?

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. inefective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Do you have a prosthetic or artificial joint?

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

Have you ever had hepatitis, jaundice or liver disease?

Do you have a bleeding problem or bleeding disorder?

Have you ever been hospitalized for any illness or operations? If yes, please explain.

If yes, please specify:

Do you have any of the following:

chest pain, angina
heart attack
stroke
shortness of breath
rheumatic fever
mitral valve prolapse
heart murmur
cancer
pacemaker
lung disease
tuberculosis
arthritis
steroid therapy
diabetes
stomach ulcers
drug/alcohol dependency
seizures (epilepsy)
kidney disease
thyroid disease
osteoporosis medications (e.g. Fosamax, Actonel)
None of the above

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

Do you smoke or chew tobacco products?

Are you nervous during dental treatment?

FOR WOMEN ONLY: Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?

If pregnant, please specify your expected delivery date:

Dental History

What is the reason for this visit? Emergency Examination Cleaning Other:

Are you currently in dental pain? Yes No

Is there a dental problem you would like to take care of as soon as possible? Yes No
If yes, please specify:

How frequently do you see your dentist? Every 3-6 months Annually Other:

Date of your last dental visit?

Date of your last cleaning?

Date of your last X-Ray?

How often do you brush per day?
How often do you floss per day?

Do your gums bleed easily? Yes No

Are your teeth sensitive to: Hot Cold Biting Sweets

Do you feel you have bad breath at times? Yes No

Have you ever had jaw joint surgery? Yes No

Do you have pain in your jaw joints or suffer from migraine headaches? Yes No

Does any part of your mouth hurt when clenched? Yes No

Does your jaw crack or pop when opened widely? Yes No

Have you had: Braces Oral Surgery Gum Treatment Root Canal

Do you grind or clench your teeth during the day or night? Yes No

Do you smoke? Number per day: Yes No
If yes, how many times per day:

Do you or does any family member have a problem with snoring? Yes No

Have you ever experienced any growths or sore spots in your mouth? Yes No
If yes, where:

Previous problems with dental treatment? Yes No
If yes, please specify:

Are you satisfied with the appearance of your teeth? Yes No
If No, please specify:

Other Dental Concerns:

Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise it may be necessary to charge for time lost.

Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medicaldental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependants is mine, and I will assume responsibility for fees associated with these services.


Patient Name:     Date:     Patient Initials:

Toronto and North York Cosmetic Multilingual Dentist Beaches
North York Cosmetic Dentist Beaches Sheppard and Yonge Dental Offices - Family Dentist in North York and Toronto Beaches Sheppard and Yonge Dental Offices - Family Dentist in North York and Toronto Beaches Sheppard and Yonge Dental Offices - Family Dentist in North York and Toronto Beaches
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