Patient Information Please enable JavaScript in your browser to complete this form.Dr.Mr.Mrs.Ms.DateName *FirstMiddleLastAgeMarital StatusMaleFemaleAddressAddress Line 1CityState / Province / RegionPostal CodeHome PhoneCell PhoneDate of BirthOccupationEmployed ByBus. PhoneDental InsuranceYesNoName of Insurance CompanySubscriber NameFirstLastDate of BirthInsurance Policy No.I.D. or Certificate No.Family PhysicianPhone No.In Case of Emergency: Name *FirstLastRelationshipPhone No. Person Responsible for Account (If not the patient) NameFirstLastPhone No. AddressAddress Line 1CityState / Province / RegionPostal CodeConfidential Medical History1. Are you presently under the care of a physician?YesNoPlease specify2. Date of last medical exam3. Are you presently taking any pills, drugs or medications? *YesNoPlease specify4. Have you take any prolonged medication in the past? *YesNoPrescription *YesNoNon-Prescription *YesNo5. Do you have any allergies to any drugs or medications? *YesNoPlease specify6. Have you been warned against taking any drugs or medications? *YesNoPlease specify7. Have you ever been hospitalized & was surgery performed? *YesNoPlease specify8. Have you had heart disease or murmur? *YesNo9. Have you had rheumatic fever? *YesNo10. Do you become breathless easily? *YesNo11. Do your ankles become swollen? *YesNo12. Have you gained or lost excessive weight recently? *YesNo13. Have you had abnormal bleeding? *YesNo14. Have you taken steroids (i.e. – cortisone)? *YesNo15. Have you ever had radiation therapy or chemotherapy? *YesNo16. Do you have any allergies *YesNoHousehold products *YesNoLatex products *YesNo 17. Do you have or have you had? please answer all questions High Blood Pressure *YesNoLow Blood Pressure *YesNoHeart Problems *YesNoChest Pain *YesNoFainting/ Dizzy Spells *YesNoBlood Disorder *YesNoAnemia *YesNoThyroid Problems *YesNoDiabetes *YesNoKidney Problems *YesNoLung Disease *YesNoTuberculosis *YesNoSinus Problems *YesNoLiver Disease *YesNoHepatitis A/B/C *YesNoDrug/Alcohol Abuse *YesNoA.I.D.S *YesNoVenereal Disease *YesNoHerpes *YesNoNervous/Anxiety Disorder *YesNoPsychiatric Care *YesNoStroke *YesNoArthritis *YesNoEpilepsy *YesNoG.I. Problems (Ulcers) *YesNoCancer *YesNoGlaucoma *YesNoJoint Replacement *YesNoType of ReplacementDate18. Are you currently in good health?YesNo19. Are there any other medical concerns you should tell me?YesNoPlease specify20. Are you, or is it possible, that you are pregnant?YesNoIf yes, what month?Confidential Dental History1. How long since your last dental visit?2. What was done at that time?3. a) Have you ever been given local anesthetic (freezing)?YesNob) Have you ever been given general anesthetic?YesNo4. Any complications with #3a or #3b?YesNoPlease specify5. Are you aware of any lump or swelling in your mouth?YesNo6. Are you interested in keeping your natural teeth?YesNo7. Are you tense during dental visits?YesNo8. Are you interested in a method to calm your nerves?YesNo 9. Do you currently experience? please check Loose TeethYesNoSensitive Teeth/GumsYesNoGagging?YesNoBleeding GumsYesNoUnexplained NosebleedYesNoHeadacheYesNoNeck PainYesNoPopping or clicking in the jaw jointsYesNoConsent for Treatment I, the undersigned, certify that all of the medical information provided is true to the best of my knowledge, and I have not knowingly omitted any pertinent information. I also consent to my physician, medical specialist, and dentist being contacted if necessary. I understand that this information is necessary to provide optimum dental care. PatientParent/GuardianDate *Name *FirstLastEmail *Submit