A parent or guardian will be responsible for decisions on my treatment: Yes   |   No

Your Name:*

Date of birth:

Your Address:*

Contact Information:

Emergency Contact:
Phone Number:
Family Doctor:
Phone Number:
Referring Doctor:
Phone Number:
Who may we thank for referring you?

Method of Payment: Cash Debit Visa Mastercard Insurance
Person Responsible for Payment: Self Spouse Parent/Guardian Other
Do you have Dental Insurance?* Yes   |   No

If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Company

Insurance Year End: (usually Dec 31)

Secondary Insurance Company (if applicable)

In. Yr. End:

Medical History

Are you presently being treated by a physician?*

If yes, please explain why:

Have you ever been hospitalized?

If yes, please explain why:

Are you taking any medications, pills, drugs, or medicine?*

If yes, please list:

Do you suffer from any allergies (hay fever, latex, etc)?

If yes, please list:

Allergies: Have you ever had a reaction to any of the following?*

Penicillin Sulfonamide Asprin Barbiturates (sleeping pills) Codeine Darvon Local Anesthetic (Freezing) General Anesthetic No Drug Allergies other (please specifiy below)

Have you ever been warned against using any other medications?

If yes, please list:

Have you ever taken prolonged medical or non-medical drugs?

If yes, please list:

Do you bruise easily or have prolonged bleeding?

Have you ever fainted, had shortness of breath, or chest pains?

Do you smoke?

If yes, how much per day?

Are you pregnant?

Are you using birth control?

Have you reached menopause?

Has your weight, appetite or energy level changed dramatically recently?

Do you follow a special diet, or are you on a diet pill therapy?

Have you or anyone in your family tested HIV positive or have Hepatitis A B C?

Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?

Have you ever had any injury or surgery to your face or jaws?

Do you wear eyeglasses or contact lenses?

Do you have any hearing difficulties?

Are you alcohol and/or drug dependent? and, Have you received treatment?

Do you have or have you had any of the following conditions. Please check all that apply:*

Angina pectoris
Anorexia nervosa
Artificial Heart Valve
Artificial joints (hips, knees)
Blood Disorders
Circulation Problems
Congenital Heart Lesions
Drug/alcohol dependence
Glandular Disorders
Head/Neck Injuries
Heart Disease/Attack
Heart Murmur
Heart Pacemaker/surgery
Heart Rhythm Disorder
Hepatitis A/B/C
High/Low Blood Pressure
HIV Positive
Hodgkin's Disease
Hyper (Hypo) Glycemia
Kidney Disease
Liver Disease
Lung Disease
Malignant Hypothermia
Mental/Nervous Disorder
Mitral Valve Prolapse
Organ Transplant/Implant
Psychiatric Disorders
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Problems
Thyroid Disease
Venereal Disease
None of the above

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Is there anything else we should know about your health?

Dental History

What is the reason for this visit? Emergency Examination Cleaning Other:

How frequently do you see your dentist? Every 3-6 months Annually Other:

Date of your last dental visit?

Date of your last X-Ray?

How often do you brush per day? Floss? Use anti-bacterial rinse?

Are your teeth sensitive to: Cold Sweets Heat Other

Do your gums bleed when: Brushing Flossing Never

Do your gums feel swollen or tender?
Do your have bad breath or bad taste in your mouth?
Do your jaws crack, pop, or grate when you open widely?
Do you grind or clench your teeth?
Do you have food catch between your teeth?
Are there any growths or sore spots in your mouth?
Have you noticed any loose teeth, or, have any of your teeth shifted?
Have you been advised to take antibiotics before a dental appointment?
Do you have any emotional concerns about having dental treatment?
Have you ever had local anaesthetic (freezing)? If yes did you have any problems?
Have you ever had any problems with previous dental treatments? If yes, please specify?
On a scale of 1 to 10, 10 being highest, how important is it for you to keep your natural teeth?

Do you have or have you had any of the following conditions. Please check all that apply:

Crowns or Caps
Dentures or partial dentures
Orthodontics (braces)
Periodontal (gums)
Root canal treatment
None of the above

Are you satisfied with your teeth? If no, please specify:

General Release:

I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Patient Name*:
Patient Initials*:

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