PERSONAL INFORMATION

Name*

Preferred Name

Birthdate*

Referred By

Address*

Province*

City*

Postal Code*

Email*

Phone*

Business

DENTAL PLAN COVERAGE: PERSONAL

Employed By

Position

SIN #

Name of Dental Insurance Co

Group #

Cert/ID #

Date Effective

Employer's Signature Required

Deductible

Coverage

Basic %

Major %

Ortho %

Financial Limit

DENTAL PLAN COVERAGE: SPOUSAL

Name of Spouse

Birthdate

Business Phone

Employed By

Position

Name of Dental Insurance Co

Patient Dependant #

Date Effective

Employer's Signature Required

Deductible

Group #

Cert/ID #

SIN #

Coverage

Basic %

Major %

Ortho %

Financial Limit

MEDICAL INFORMATION

Physician's Name *

Location *

Dr Phone #

When was your last complete physical exam?

Are you being treated by a physician at this time?

Are you taking any pills, drugs, medications or herbal supplements?

Do you have any drug allergies?

Have you been hospitalized or had any surgery in the past (5) years?

Do You Have a History of:
(select all that apply - hold down the control key for multiple selections)

Have you ever had any traumas or injuries to the head and neck?

Are you pregnant or could you possibly be pregnant?

Have you ever been advised to take medication such as antibiotics prior to your dental appointments?

Do you have any other significant illnesses?

DENTAL HISTORY

Previous Dentist’s Name

Location

Last Dental Visit (MM/YY)

Last Dental X-Rays (MM/YY)

Last Dental Hygiene Visit (MM/YY)

Are you anxious at dental appointments?

Do you have a problem with the local anaesthetic?

Do You Have a History of:
(select all that apply - hold control key for multiple selections)

GENERAL INFORMATION

Are you on a regular dental hygiene maintenance program?

Have you had any bad experiences at the dentist?

Have you been satisfied with your past dentistry?

Have you ever gone 5 years without needing any dentistry?

How would you rate your present dental health?

Why would you rate yourself that way?


How do you feel about the appearance of your teeth?

If you could change one thing about your mouth, what would it be?

How can we help you?

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