patient form

Please be advised all Information is private and confidential

Please be sure to bring your insurance information to your first visit

 

Patient Information(Adult Information)

Preferred contact methodTextEmailCall MobileCall Home

How did you hear about us?FlyersDrive/Walk byOnlineFriends and family (who may we thank)Other

Emergency Contact Information:



Today's Visit

Reason for this appointment?

Do you have dental insurance?YesNo

Your Medical History

Family Physician:

Phone Number:

Address:

City:

Postal Code:

Specialist:

Phone Number:

Date of your last Physical Exam:

Date of your last visit with your doctor:

Would you consider yourself to be in good health?

Have you been hospitalized in the past 2 years?

Reason:

Have you had any surgeries? Kindly mention the Date:

Reason:

Do you smoke?

WOMEN only: Are you pregnant?

Please list all medications you are currently taking:

Medical Conditions:

Please indicate any conditions you currently have or have had in the past:

Cancer

High Blood Pressure

Low Blood Pressure

Diabetes Type 1

Diabetes Type 2

Stroke

Heart Problems

Artificial Heart Valve

Mitral Valve Prolapse

Heart Attack

Blood/Bleeding Disorders

Angina Pectoris

Kidney Disease

Osteoporosis

Arthritis/Gout

Thyroid Disease

Pacemaker

AIDS(HIV)

Anemia

Asthma

Cold sores

Liver Disease(Hepatitis A, B, C)

Mental/Nervous Disorders

Fainting/Dizziness

Sinus Trouble

Heart Palpitations

Epilepsy / Seizures

Malignant Hyperthermia

Crohn's Disease

Ulcers/ Stomach concerns

Lung disease

Drug/Alcohol Addiction

Congestive Heart Failure

Bleeding disorder

Headaches

Hernia

Artificial Joints

Hip / Knee replacement

Emphysema

Are you taking any blood thinners? (Warfarin / Coumadin / Plavix / Aspirin /Other)

List:

Are there any other medical concerns we should be aware of?

Allergies and Reactions:

Please indicate which medications or materials you are allergic to, or have had a reaction to in the past:

Aspirin(ASA)

Ibuprofen(ADVIL)

Acetaminophen (TYLENOL)

Codeine(TYLENOL 1,2 or 3)

Percocet/ Oxycocet

Tetracycline

Penicillin/Amoxicillin/Ampicillin

Erythromycin

Clindamycin

Local Anaesthetic(Freezing)

Latex

Nitrous Oxide

Chlorhexidine(PERIDEX)

Metal Allergy

Cephalosporins(KEFLEX)

Sulfa Drugs

Other drugs or material allergies not listed above:

Patient Signature:

Dentist Signature:

Date:


_____________________________________________ for office use only_________________________________________




Policy holder Date of Birth

Please take a minute to print and fill out the patient form ahead of your first visit to save you time!