New Patient Intake Form New Patient Intake Form "*" indicates required fields Name* First Middle Last Birthdate* DD slash MM slash YYYY Age*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email* Home Phone*Work PhoneCell PhoneOccupationEmployerFamily DoctorFamily Doctor's PhoneEmergency contactHow did you hear about us?* Postcard Yellow Pages Smile Insider Website Walk-by Northern Edge Newsletter (community) Other Description*Friend/Family Referral (name)Dental Insurance InformationInsurance Company #1 Yes Insurance Company #1*Policy/Group #*ID #*Policy Holder's Name*Policy Holder's Birth Date* DD slash MM slash YYYY Insurance Company #2 Yes Insurance Company #2*Policy/Group #*ID #*Policy Holder's Name*Policy Holder's Birth Date* DD slash MM slash YYYY Policy Holder's Employer*Medical HistoryAre you currently in good health? Yes No Are you currently taking any medications or vitamins (prescription, over-the-counter, recreational)? Yes No Which medications?Do you currently smoke? Yes No Are you allergic to or ever had a reaction to any of the following: Penicillin Codeine Local Anesthetic (“freezing") Aspirin (ASA) Sulfa Drugs Other If Other, please specify:Are you under the regular care of a physician? Yes No Do you bleed more or longer than normal after a cut, bruise, surgery or previous tooth removal? Yes No Have you ever had a serious illness or operation? Yes No Do you currently have or ever had any of the following conditions? Heart Trouble or Stroke Heart Murmur Thyroid Disorder Rheumatic Fever Breathing Problems Arthritis HIV Positive Tumours or Cancer High Blood Pressure Low Blood Pressure Hepatitis Liver Disease Kidney Disease Mental Illness Diabetes Tuberculosis Epilepsy or Seizure Blood Disorders Hormonal Disorder Anxiety Other Women: Are you pregnant? Yes No Is there anything else we should know about your health? Yes No If yes, please specify:Dental HistoryWhat dental condition(s) concern you at present?When was your last dental check-up and cleaning?Were X-rays taken at your last dental visit? Yes No When was the last time you changed dental offices?Have you noticed any signs of the following? Bleeding Gums Drifting of Teeth Gum Ache Receding Gums Loose Teeth Do you have any clicking, popping or pain in your jaw joint? Yes No Are you aware of clenching or grinding your teeth? Yes No Do you have any missing teeth that you feel should be replaced? Yes No Would you like to improve the appearance of your teeth? Yes No Do you floss your teeth? Yes No Have you had any complications or difficulty with previous dental treatment? Yes No How do you rate yourself as a dental patient? Calm Slightly Very Anxious ConfirmationConsent* I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthesia.Privacy Policy* By checking this box, I understand and agree to the Privacy Policy as well as the Office Policy found on the contact page.EmailThis field is for validation purposes and should be left unchanged. Δ New Patients Welcome Take Care Of Your Oral Health & Book Your Dental Hygiene Appointment Today Request Appointment
