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New Patient Form
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Name
*
First
Middle
Last
Birthdate
*
DD slash MM slash YYYY
Age
*
Address
*
Street Address
City
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British Columbia
Manitoba
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Postal Code
Email
*
Home Phone
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Work Phone
Cell Phone
Occupation
Employer
Family Doctor
Family Doctor's Phone
Emergency contact
How did you hear about us?
*
Postcard
Yellow Pages
Smile Insider
Website
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Northern Edge Newsletter (community)
Other
Description
*
Friend/Family Referral (name)
Dental Insurance Information
Insurance 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 History
Are 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 History
What 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
Confirmation
Consent
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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
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By checking this box, I understand and agree to the
Privacy Policy
as well as the
Office Policy
found on the contact page.
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This field is for validation purposes and should be left unchanged.
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Exams and Hygiene
Emergency Dental Care
General Checkups
Children’s Dental Hygiene
Cosmetic Dentistry
Veneers
Whitening
Invisalign®
Restorative Services
Crowns
Bridges
Fillings
Implant Dentistry
Partial Dentures
Dentures
Root Canal Therapy
Oral Surgery
Nitrous Oxide Sedation
Oral Sedation
Wisdom Teeth
Extractions
Oral Appliances
Snoring & Sleep Apnea Solutions
Sports Guard
Technology
Velscope Screening
Laser Therapy
