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!