Patient Registration Form

PATIENT INFORMATION

First Name

Last Name

Date of Birth

Address

City

Postal Code

Home Phone

Cell Phone

Email

In case of emergency please contact:

Emergency Contact Number

WORK INFORMATION

Employer

Occupation

Work Phone

Address

if this form is filled for another person write the guardian (responsible person) name below

INSURANCE INFORMATION

Primary Insured

Date of Birth

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

If covered under spouse’s plan as secondary coverage:

Secondary Insured

Date of Birth

Employer

Insurance Company

Group / Policy Number

ID / Certificate Number

MEDICAL HISTORY

Name of Physician

Address of Physician

Office Phone Number

Are you currently under medical treatment?

Yes No

Reason (if yes)

Have you had an allergic or unusual reaction to any of the following?
(Leave blank if all answers are No)

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetic

Yes No

Penicillin

Yes No

Other

FOR WOMEN ONLY

Are you Pregnant?

Yes No

If yes, Expected date of delivery

Have you ever been treated for any of the following?
(Leave Blank if all answers are No)

Anemia

Yes No

Asthma

Yes No

Diabetes

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Murmurs

Yes No

Hepatitis

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Rheumatic Fever

Yes No

Sinus Trouble

Yes No

Stroke

Yes No

Tuberculosis

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Other

Please answer all questions below:

Have you ever been treated for AIDS-related complex?

Yes No

Details

Are you taking any medications? If so, what are they?

Yes No

Medications

Do you have heart trouble? If so, what kind?

Yes No

Details

Do you have high or low blood pressure? Is it controlled?

Yes No

Details

Have you ever been required to take prophylactic antibiotics prior to dental treatment?

Yes No

Details

Do you use tobacco products? If so, how often?

Yes No

Details

Are you subject to fainting or dizziness? If so, how often?

Yes No

Details

Have you ever had cancer or a tumor? If so, how was it treated?

Yes No

Details

Have you ever had any major operations? If so, what kind?

Yes No

Details

Have you ever been involved in a serious accident?

Yes No

Details

Do you bruise or bleed easily?

Yes No

Details

Have you recently had a communicable disease (i.e. Mumps, Measles, etc.)?

Yes No

Details

Dental History

Previous Dentist

Address

Phone Number

Fax Number

Date of Last Visit

In past years have you been to a dentist on a regular basis? If so how often?

Are you presently in any dental pain?

Is any part of your mouth sensitive to temperature, pressure or sweets?

Have you ever had orthodontic treatment?

Do your gums bleed when brushing your teeth?

Do you have an unpleasant taste or odor in your mouth?

Do you get growth or swelling after tooth extractions? If so, for how long?

Have you ever gotten food stuck between your teeth?

Do you awaken with pain in your teeth or jaws?

Do you have frequent headaches or facial pain?

Are you aware of jaw clicking or popping while eating or yawning?

Do you ever get cold sores or fever blisters?

What is your major dental concern at this time?

Name of Patient (or the responsible person)

Date Signed

Message

By checking this checkbox, I hereby understand and agree to the terms and conditions.

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Patient Registration Form

Fifth St Dental
Dentist in Etobicoke

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Patient Registration Form

Fifth St Dental Dentist in Etobicoke

Brighten your smile with SmileOn!

Fifth St Dental
Dentist in Etobicoke