Personal Information

Patient First Name:
Middle Initial:
Last Name:
Birthdate:
Age:
Gender:
Mother First Name:
Middle Initial:
Last Name:
Father First Name:
Middle Initial:
Last Name:
What would you like to improve about your smile?

Address:
City:
Province:
Postal Code:
Primary Phone:
Secondary Phone:
Email:

Dental History

Dentist Name:
Phone:
Whom may we thank for referring you to our practice?
Last dental visit?
In Case Of Emergency Notify:
Phone:
Person Responsible For Payments:

Dental Insurance Information

PLAN #1
Policy Holder's Name:
Birthdate:
Name of Insurance Company:
Group/Policy/Cert. #:
Subscriber ID:
PLAN #2
Policy Holder's Name:
Birthdate:
Name of Insurance Company:
Group/Policy/Cert. #:
Subscriber ID:

Medical History

Physician Name:
Phone:
Have you ever been a patient in hospital during the past 2 years?
Have you been under the care of a physician during the past 2 years?
Have you taken any kind of drugs or medicine in the past 2 years?
Are you allertic to latex, penicillin or any other drugs or medications?
Do you ever have chest pains?
Have you ever experienced unexplained shortness of breath?
Have you ever experienced excessive bleeding that required special treatment?
Have you ever had any of the following? (Please select YES)
AIDS?
Anemia?
Anorexia/Bulimia?
Artificial Heart Valve?
Arthritis or joint problems?
Asthma?
Cancer?
Circulation Problems?
Congenital Heart defect?
Diabetes?
Emphysema?
Epilepsy?
Head/Neck Injury?
Heart Problems?
Hepatitis A/B/C?
High/Low Blood Pressure?
HIV+?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Lung Disease?
Mental disorders?
Mitral Valve Prolapse?
Radiation/Chemotherapy?
Rheumatic/Scarlet Fever?
Stroke?
Tuberculosis?
If any of the above were answered YES, please elaborate
Have you ever had any other serious illness?
(Women) Are you pregnant now?
Comments (e.g. elaborate on any "YES" response)
Signature:
Date: