Hamilton Care Dental – New Patient Form

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 dental provider-patient confidentiality. The dental provider will review the questions and explain any that you do not understand.
Please fill in the entire form.

New Patient Form

Hamilton Care Dental – New Patient Form
Name
Name
First
Last
Sex
Marital Status

Primary Insurance

Does Patient Have Primary Insurance
Subscriber Name
Subscriber Name
First
Last

Secondary Insurance

Does Patient Have Secondary Insurance
Subscriber Name
Subscriber Name
First
Last

Dental History

Have you been seeing a dentist/dental hygienist regularly? If not, why not?
Are you nervous during dental visits?
Have you had a bad experience or complications during dental treatment?
Have you ever seen a dental specialist?
Bleeding Gums
Bad Breath
Jaw Problems
Grinding/Clenching
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?

Medical History

Do You Have Any Allergies
If yes, please list them using the categories below:
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
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? If yes, please explain.
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? If yes, please list. Yes
Have you ever had hepatitis, jaundice or liver disease? If yes, please clarify.
Do you have any bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
Do you have or have you had any of the following? Please check
Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?
Do you smoke or chew tobacco products?
Have you been told to take antibiotics before a dental appointment?