Monarch Tremont Medical History -

Todays Date:

Patients Information

Name

First

Last

DOB:

Home Address

Unit Number

City

Postal Code

Home Phone

Cell Phone

Email

Occupation

Physician

#

Specialist

#

Dentist

#

Emergency Contacts

Name

Phone #

Relationship

Do you have dental Insurance (YES/NO)

Policy Holder

DOB

Insurance Provider

Policy #

ID #

Employer

How did you hear about our office

Medical History

Are you being treated for any medical conditions, if so why? YES / NO If yes, please explain:

When was your last medical check-up?

Has there been any change to your general health in the past year? YES/NO If yes, please explain:

Are you taking any medications, non-prescription drugs of any kind? YES /NO If yes, please list:

Consent to contact pharmacy to retrieve medication list: YES / NO Name and Number of Pharmacy:

Do you have any ALLERGIES? YES / NO If yes, please list using categories below:

Medications

Foods

Other

Have you ever had problems with local anesthetic (freezing) problem? YES / NO If yes, please explain:

Have you ever had radiation or X-ray therapy (ex? chemotherapy) YES / NO If yes, please explain:

Do you have/had asthma? YES / NO If yes, please have inhaler with you during your appointment

Do you have or had any heart or blood pressure problems? YES / NO If yes, please explain:

Do you have or had a replacement or repair of 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? YES / NO If yes, please explain:

Do you have a prosthetic or artificial joint? if yes, please explain, Provide Year:

Have you ever had hepatitis, jaundice (other than birth) or liver disease? YES / NO

Have you ever been hospitalized for any illnesses or operations? YES / NO If yes, please explain:

Do you have or have had any of the following:

Are there any disease or medical problems that run in your family? (i.e diabetes, cancer or heart disease) YES / NO if yes, please list:

Do you smoke or chew tobacco products?> YES / NO

If yes, How many per day

If yes, Number of years

Dental History

Last Dental Visit

What was done?

How frequent do you see your dentist

When was Your last x-rays Taken

How would you describe your oral health at present? GOOD / FAIR / POOR

What are you present dental concerns, if any? Please check

Please specify if there is OTHER

Have you had any teeth extracted due to accident, decay or gum disease? YES / NO Please explain:

Have you ever had any complications after extraction? YES / NO Please explain:

Have you been taught PREVENTATIVE ORAL HYGIENE? YES / NO

Are you anxious during dental visits? YES / NO please explain:

For Woman Only

Are you pregnant? YES / NO / NOT SURE-MAYBE

Are you breastfeeding? YES / NO

Are you taking birth control medication? YES / NO

Patient Information And Consent

SIGNATURE; OF PATIENT OR PARENT/GUARDIAN IF UNDER 16*

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Date

DENTIST’S SIGNATURE

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Date

Welcome to our office Monarch  Smile Dental Centre Tremont location. It is our philosophy and Beliefs to provide the ultimate care with the most comnaround comfort and satisfaction. We intently listen to your desires and create the unique smile that you want and deserve. We feel passionate about each and every smile that we create. Our highly trained team will ensure an experience above and beyond your expectations.

Appointment Responsibility & Scheduling

Your connection in making and keeping appointments is essential. Please let us know of any change in your schedule at least two business days* prior to your scheduled appointment. The appointment time can then be made available to others in need of dental care.
<ul>
 	<li style="font-weight: 400;" aria-level="1">1st Missed Appointment: If an appointment is missed or cancelled without sufficient notice, a call will be placed reminding you of our policies and the effects of your missed appointment.</li>
 	<li style="font-weight: 400;" aria-level="1">2nd Missed Appointment: After your second missed appointment, a charge will be applied on your account of $50.00 this fee must be paid prior to appointing another visit. This fee will be credited ONLY if your missed appointment is scheduled within 3 weeks’ time of your missed appointment and upon arrival at this scheduled appointment.</li>
 	<li style="font-weight: 400;" aria-level="1">Late Appointments: Please understand that we reserve time just for you. During this time we aim to provide with the best quality work possible. If you arrive more than 15 minutes late, your appointment may have to be re-scheduled in order to meet the needs of those who are on time for their pre-reserved visit. If this happens, it will be considered a missed appointment.</li>
</ul>

Fees, Payments & Insurance

Our fees are based on the current provincial general practitioner’s fee guide which is issued by the Ontario Dental Association each year.

If you have dental insurance coverage, we can submit your dental claim directly from our office electronically. We also accept assignment of benefits (payment from your insurance carrier-provided that it is allowed under your specific policy). However, you will be responsible for your co-payment (any account that is not covered under your insurance policy) at each appointment.

If you do not have dental insurance, payment for professional service is due at the time of dental treatment is provided. We accept cash, most major credit cards and interact (debit) as a form of payment. Our office also offers suitable payment plan options for your convenience.

If you have any other questions regarding any of our office policies or procedures, please feel free to ask one of our knowledgeable and friendly staff members.

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Monarch Tremont Medical History

Monarch Dentistry

St. Catherines – Tremont

Patients Information

Emergency Contacts

Medical History

Dental History

For Woman Only

Patient Information And Consent