- My Forms at Home

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

Home #

Work #

Ext.

Mobile #

Other #

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 #

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

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

MEDICAL HISTORY

Please fill to the best of your knowledge, leave blank if you are unsure

17. Do you have or have you ever had any of the following?

Please check all that apply

18. Are there any conditions or diseases not listed above that you have or have had

Yes

No

If yes, please explain

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

Yes

No

If yes, please explain

20. Do you smoke or chew tobacco products?

Yes

No

if yes, what quantity and how often?

WOMEN ONLY

21. Are you pregnant or suspect you may be?

Yes

No

If yes, what is the expected delivery date?

22. Are you taking any birth control pills?

Yes

No

DENTAL HISTORY

23. Name and phone number of the last dentist you saw?

24. What was the approximate date of your last dental visit?

25. What was the approximate date of your last dental cleaning?

26. What was the approximate date of your last xrays?

Have you ever had the following? Please check all that apply.

27. Periodontal Treatment? (treatment of the gums)

28. Orthodontic Treatment? (to straighten or align teeth)

29. Oral Surgery? (surgery in or around the mouth/jaw joint or implant surgery)

30. A bite plate or any other appliance?

31. Are you currently under the care of a dental specialist? (ie. orthodontist, periodontist)

CURRENT CONDITIONS

Please check off all that apply

CONCERNS

PATIENT PRIVACY INFORMATION

When unusual requests are received, we will contact you for the permission to release such information.  We may also advise you if such a releas eis inappropriate.  You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code and I can ask to see that Code at any time.

SIGNATURE

Patient/Parent/Guardian Signature

Please type your name

Dentist Signature

Reviewing dentist name