Burlington Dental Centre New Patient
Burlington Dental Centre
New Patient Form
BDC New Patient Form
Title:
Mr.
Mrs.
Ms.
Mst.
Miss.
Dr.
Name
Name
First Name
First Name
Last Name
Last Name
Initial
Nickname
Date Of Birth (DD/MM/YY)
Home Address
Suite
City
Province
Postal Code
Home Phone
Cellular Phone
Business Phone
Email
Occupation
Name Of Gaurdian/Parents: (if under 18 or gaurdianship)
Phone: (If not same as above)
Address: (If not same as above)
(1)Name of family doctor:
Phone or address
(2)Name of specialist
Phone or address
Pharmacy Name/Number
Driver’s License number
OHIP number:
Do you have dental Insurance
Yes
No
Employer
Primary Ins. Policy #/Cert.#:
Secondary Ins. Policy#/Cert.#
How did you hear about our office?
In case of emergency, we should notify:
Name
Relationship
Phone
Dental History
1. When was your last dental visit?
2. When was your last cleaning?
3.Who was your previous dentist?
Did you have x-rays taken within the last 2 years?
Yes
No
5.How would you describe your dental health at present?
Good
Fair
Poor
6. What are your present dental concerns, if any?
Bleeding Gums
Crooked teeth
Cosmetic
Loose Teeth
Bad Breath
Food trapping
Sensitive teeth
Toothache
Loose Dentures
Missing teeth/spaces
Want whiter teeth
Other
Other
7. Are you dissatisfied with the appearance of your teeth?
Yes
No
Maybe/Not Sure
8. Any teeth extracted due to accident, decay or gum disease? If Yes Please explain
Yes
Yes
No
Maybe/Not sure
9. Have you ever had complications after extractions? If Yes Please explain
Yes
Yes
No
Maybe/Not Sure
10. Do you use any of the following as part of your oral hygiene regiment?
electric toothbrush
floss
softpics
proxybrush
stimudent
flosswand
toothpick
rubbertip
waterpic
fluoride rinse/tablet
fluoridated toothpaste
natural toothpaste
prevident toothpaste
Other:
Other:
11. Are you anxious during dental visits?
Yes
No
Maybe/Not Sure
12. Do you think you might like to have your dental treatment done with sedation?
Yes
No
Maybe/Not Sure
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. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have been treated within the past year? If so, why?
Yes
Yes
No
Maybe/Not Sure
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year? If yes, please explain. ☐Yes ☐No ☐Maybe/Not Sure
Yes
Yes
No
Maybe/Not Sure
4. Are you taking any medications, non-prescription drugs, natural supplements of any kind? If yes, please list with doses or provide list.
Yes
Yes
No
Maybe/Not Sure
5. Do you have any allergies? If yes, please list below
Yes
No
Maybe/Not sure
a) Medications
b) Latex / rubber products/ metals
c) Other (eg. hayfever, foods, dyes)
6. Have you ever had a peculiar or adverse reaction to any medications or injections? If yes, please explain.
Yes
Yes
No
Maybe/Not Sure
7. Do you have or ever had asthma?
Yes
No
Maybe/Not Sure
8. Do you have or ever had any heart or blood pressure problems?
Yes
Yes
No
Maybe/Not Sure
9. Do you have or ever had a replacement or repair of a heart valve, infection of the heart (infective endocarditis), a heart condition from birth (congenital heart disease) or a heart transplant?
Yes
Yes
No
Maybe/Not Sure
10. Do you have a prosthetic or artificial joint? (i.e. knee or hip?)
Yes
Yes
No
Maybe/Not Sure
11. Do you have any condition or therapies that could affect your immune system? (i.e. chemotherapy, radiotherapy, leukemia, AIDS/HIV infection) ☐Yes ☐No ☐Maybe/Not Sure
Yes
Yes
No
Maybe/Not sure
12. Have you ever had hepatitis, jaundice (other than birth) or liver disease?
Yes
Yes
No
Maybe/Not Sure
13. Do you have a bleeding problem or bleeding disorder?
Yes
Yes
No
Maybe/Not Sure
14. Have you ever been hospitalized for any illness? Or had any surgeries? If yes, please explain.
Yes
Yes
No
Maybe/Not Sure
15. Do you have or ever had any of the following? Please check.
Chest pain, angina
Seizure (epilepsy)
Arthritis
Diabetes
Mental health disorder
Rheumatic fever
Stroke Prelapse
Hypothermia
Cancer
Pace maker
Lung disease
Stomach ulcers
Heart attack
Tuberculosis
Osteoporosis medications (e.g.Fosamax, Actonel)
Malignant
Shortness of breath
Heart murmur
Steroid therapy
Kidney disease
Mitral valve
Thyroid disease
Organ transplant
Drug/alcohol dependency
High Blood Pressure
Low Blood Pressure
16. Are there any conditions or diseases not listed above that you have or have had? If so, what?
17. Are there any diseases that run in your family (e.g. diabetes, cancer, heart disease) If yes, please explain.
Yes
Yes
No
Maybe/Not Sure
18. Do you smoke /use tobacco/marijuana products?
yes
No
If yes, how much per day?
How many years?_____
FOR WOMEN ONLY
1. Are you pregnant? If Yes, Expected delivery date?
Yes
Yes
No
Maybe/Not Sure
2. Are you breast feeding?
Yes
No
3. Are you on birth control pills?
Yes
No
PATIENT CERTIFICATION AND 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 any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. Unless other arrangements are made payment is due at each office visit. Unpaid accounts may be subject to interest. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and the dentist. I authorize the dentist to treat me and I assume full responsibility of the fees. I am aware that 2-business days notice is required to change or cancel an appointment without charge.
I am aware that 2-business days notice is required to change or cancel an appointment without charge
Signature (parent or guardian if under 18 years old)
signature
keyboard
Clear
Date: (DD/MM/YY)
Submit
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