Forms

New Patient Form

We understand that your time is valuable. To streamline your first visit, please complete this form prior to your appointment. If you prefer to complete the form in the office, kindly arrive 15 minutes before your scheduled appointment.

Are you a new or existing patient?

NewExisting

Referral Information

How did you hear about our clinic?

Social MediaSearch EngineRadioLives in AreaWorks in AreaFriend/FamilyPatient ReferralEmployee ReferralEventOther

If other, please specify:

Patient Information

Patient Type:

AdultChildAdult Under Guardianship

Gender:

MaleFemaleOther

Name:

Date of Birth:

Address:

Email:

Phone Number:

Marital Status:

SingleMarriedCommon Law

Employer Name:

Family Physician Name:

Specialist Name:

Emergency Contact Phone Number:

Insurance Information

Insurance Company Holder:

SelfSpouseParent/Guardian

Insurance Company Name:

Name of Insurance Policy Holder:

Policy Holder Date of Birth:

Group Policy/Plan Number:

ID/Certificate Number:

Financial Information

Person Responsible for Account:

SelfSpouseParentOther

Name of Person Responsible for Account:

Preferred Method of Payment:

InteracVisaCashMastercard

Dental Information

Date of Last Dental Exam:

Date of Last Dental Cleaning:

Date of Last Dental X-rays:

Please check any of the following problems that may apply to you:

Sensitivity (hot, cold, or sweet)Tooth pain or discomfort while chewingHeadaches, earaches, or neck painJaw joint pain (clicking/cracking)Grinding or clenching teethBleeding, swollen, or irritated gumsLoose, chipped, or shifting teethBad breath or bad taste in your mouth

Do you have or have you had any of the following?

DenturesOrthodonticsPartial DenturesPeriodontal (gum) treatments

If you could change your smile, you would:

Make teeth brighterMake teeth straighterClose gaps between teethReplace metal fillings with natural tooth-colored fillingsRepair chipped teethReplace missing teethReplace old crowns that don’t matchHave a smile makeover

Medical History

Are you currently being treated for any medical condition or have you been treated within the past year?

YesNo

When was your last medical checkup?

Are you taking any medications?

YesNo

Do you have any allergies?

YesNo

Do you have or have you ever had any of the following?

AsthmaHeart ProblemsDiabetesCancerTuberculosisOther (please specify below)

General Release

I agree to the cancellation policy and confirm that the information I have provided is accurate.