Skip to content
Cliniforms
Hamilton City Dental new patient
Hamilton City Dental
New Patient Forms
Hamilton City Dental New Patient Form
Date
Age
PID#
Medical Alert
Yes
No
Registration Information
Patient is a
Adult
Child
Adult under Gaurdianship, name:
Adult under Gaurdianship, name:
Patient Name
Patient Name
First
First
Last
Last
Initial
Dr.
Mr.
Ms.
Mrs.
Miss.
Address: Street
Unit/Apartment/Suite #
City & Province
Postal Code
Address: Street 2 (if applicable)
Home Phone
Cell Phone
Bus. Phone
Ext.
Employer
May we call you at work?
Yes
No
Email Adress
Prefers to be called
Occupation:
Date Of Birth
Date Of Birth
Month
Month
Day
Day
Year
Year
Age
Gender
Martial Status
Name of Spouse
Name of Spouse
First
First
Last
Last
Are other family members patients at our office?
No
Yes, Name:
Yes, Name:
Whom we may thank for referring you
Family Physician
Phone
Medical Specialist
Phone
In Case Of Emergency Contact:
Phone
Primary Insurance
Patient Name
Patient Name
First
First
Last
Last
Date Of Birth
Employer Name
Insurance Company
Group #
ID / CRT #
Secondary Insurance
Patient Name
Patient Name
First
First
Last
Last
Date of Birth
Employer Name
Insurance Company
Group #
ID / CRT #
Dental History
Date of your last dental visit
Last dental cleaning
Last X-ray
1. Do you have any dental problems or concerns you would like to have checked right away?
2. Please describe any current or past dental treatments, procedures, or concerns:
3. Is there anything else about your dental health or history we should know?
Health History
1. Has there been any changes in your general health in the past year?
Last Physician visit:
Last physical:
2. List any PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken (including birthcontrol pills):
3. List all medical conditions:
4. Are you being treated for any medical condition at present or within the past year? If yes, please specify:
5. Any adverse reactions to medications/injections or allergies? Please specify:
6. Have you ever been advised against taking any specific type of medication?
Yes
No
7. Do you bleed excessively/bruise easily, are you on cortisone/steroid therapy, have artificial joints, or requireantibiotics before dental treatment? Please explain
8. Do you have or have you ever had any heart problems, shortness of breath, or heart palpitations?
Yes
No
9. Do you have any infectious diseases, conditions that affect your immune system, or have youever had malignant disease/undergoing radiation/chemotherapy?
Yes
No
10. Do you, or did you smoke? Do you drink alcoholic beverages on a regular basis? Use Recreational Drugs?
Smoke
Yes
No
Alcohal
Yes
No
Recreational Drugs
yes
No
11. WOMEN ONLY: Are you pregnant?
Yes
No
If pregnant, delivery date?
Are you breast feeding?
Yes
No
12. Is there anything else about your health we should be made aware of?
13. How Did You Hear About Our Office?
General Release
I, the undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical dental history. 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 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. 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.
Who is signing
Patient
Parent
Gaurdian
Patient Name
Patient Name
First
First
Last
Last
Signature
signature
keyboard
Clear
Date
Reviewed by treating dentist
Date
Submit
Start Over
If you are human, leave this field blank.
