New Patient Form - Kanata smiles | trusted dental clinic in Kanata

New Patient Medical History Form

We understand that your time is valuable and in order to streamline your first visit, simply complete at your convenience, prior to your appointment.

How did you hear about us? *

Are you a new or current patient? *New PatientCurrent Patient

Patient Contact Information

Patient Type *AdultChildAdult Under Guardianship

First Name of Guardian *

Last Name of Guardian *

Gender *

First Name of Patient *

Last Name of Patient *

Date of Birth *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Country

Email Address *

Primary Phone Number *

Home Phone Number

Work Phone Number

Best way to contact youPrimaryHomeWork

Preferred Time to Contact

Hours

Minutes

AM/PM

Preferred Method of Contact *

Family Physician *

Specialist Name

Emergency Contact *

Emergency Contact Phone Number *

Insurance Information

Primary Insurance Company

Insurance Policy Holder *SelfSpouseParent/GuardianNone of the Above

Secondary Insurance Company Information

Insurance Policy HolderSelfSpouseParent/GuardianOther

Describe

Insurance Company Name

Name of Insurance Policy Holder

Policy Holder Date of Birth

Group Policy/Plan Number

ID/Certificate Number

Financial Information

Person responsible for account *SelfSpouseParent/GuardianOther

Describe

Preferred Method of Payment *InteractVisaCashMastercard

Dental History

Date of your last dental exam *

Date of your last dental cleaning *

Date of your last dental x-rays *

Please check any of the following problems that may apply to you. *Sensitivity (hot, cold and/or sweet)Tooth pain or discomfort while chewingHeadaches, earaches or neck painJaw joint pain (clicking/cracking)Grinding or clenching teethBleeding, swollen or irritated gumsLoose, chipped or shifting teethBad breath or bad taste in your mouthNone of the above

If you could change your smile, you would… *Make your teeth brighterMake your teeth straighterClose gaps between teethReplace metal fillings with natural tooth coloured fillingsRepair chipped teethReplace missing teethReplace old crowns that don’t matchHave a smile makeoverNone of the above

How important is your dental health to you? *

On a scale of 1 to 10, with 10 being the highest rating

Where would you rate your current dental health? *

Why are you leaving your previous Dentist?

What, if anything, in the past has kept you from having dental treatment?

What is the most important thing about your future smile and dental health?

What is most important thing to you about your upcoming visit?

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year? *YesNo

Please Describe

Has there been any change in your general health in the past year? *YesNo

Please Describe

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *YesNo

Please Describe

Do you have any allergies? *YesNo

Please Describe

Have you ever had a peculiar or adverse reaction to any medicines or injections? *YesNo

Please Describe

Do you have or have you ever had asthma? *YesNo

Please Describe

Do you have or have you ever had any heart or blood pressure problems? *YesNo

Please Describe

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *YesNo

Please Describe

Do you have a prosthetic or artificial joint? *YesNo

Please Describe

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *YesNo

Please Describe

Have you ever been hospitalized for any illnesses or operations? *YesNo

Please Describe

Are there any conditions or diseases not listed above that you have or have had? *YesNo

Please Describe

Do you smoke or use other nicotine products? *YesNo

Please Describe

Are you pregnant? *YesNo

Expected Due Date

Are you breastfeeding? *YesNo

Do you have a disability or are a person with visual impairment? *YesNo

Please Describe

General Release

I agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment. *I agreeI do not agree

Acknowledgment and Consent *I certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.

Date *