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PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Gender

Date of Birth

Address

Province/State

City

Postal /Zip Code

Phone #

Type

Ext

Phone #

Type

Ext

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

NEW PATIENT HEALTH HISTORY FORM

The patient is an:

Adult

Child

Adult under guradianship

If guardian, please type the name of the guardian

Pharmacy Information (name, phone, fax)

DENTAL HISTORY

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health history have an important relationship with your dental treatment. Please answer the following questions.

MEDICATIONS

If you are not taking any medications, please type "none" in the box below.

List any PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken.

HEALTH HISTORY

Please go over the following section and indicate which of the following you have had. &edsp;Please provide additional information, such as dates of incident or surgeries that coincide with condition, in the text box below.&edsp;

Please go over the following section and indicate which of the following you have or have had. Please provide additional information, such as dates or health conditions not listed, in the text box below.&edsp;

CHILDREN ONLY

Please list any medical conditions or illnesses the child has recently had. This can include Measles, Strep Throat, Tonsillitis.

PATIENT CERTIFICATION & CONSENT

I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted pertinent information.&edsp;&edsp;Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I consent to the collection and documentation of my personal information in any manner or for any purpose whatsoever but only for the purpose of, concerning or relating to my dental health care. I understand that 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, but only in accordance with the Regulated Health Professions and the Dentistry and Dental Hygiene Acts of Ontario. 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.&edsp;

Further, we are now a paperless office, and all patient information is securely stored in our central electronic database. Should it be necessary to share your information with dental specialists or other healthcare professionals involved in your care, all data will be transmitted using secure encryption methods.

I consent to your office contacting me directly or leaving a message for any and all purposes relating to my dental care and/or appointments.

Yes

No

If yes, please choose preferred contact method

Home Phone

Cell Phone

Work Phone

Email

Patient Signature