New Patient Form

Date

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

Patient Full Name *

Prefers to be called:

Language Preference

Address (Full residential address required) *

Please include city and post code.

Phone Numbers: *

Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.

Date Of Birth *

I consent to be contacted by Email if I have provided my Email address to the office.

Marital Status:

Preferred appointment time: *

Whom may we thank for referring you?

Are other family members patients at our office?

MEDICAL INFORMATION:

Family Physician:

Phone Number:

In case of emergency, please contact:

Phone Number:

Reason for today’s visit?

HEALTH HISTORY:

(Please answer yes or no. If unsure of a question, please consult with the dentist.)

Are you being treated for any medical condition at present or within the past two years?

If yes, please explain:

When was your last visit to a Physician?

Complete Physical?

Have you recently, or are you presently, taking any prescriptions or non-prescription drugs including herbal remedies?

If so please list.

Have you ever reacted adversely to any medications or injections?

If yes, please list:

Have you ever been advised against taking any specific types of medication?

If yes, please list:

I, 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 either my health/dental status or any other information I have provided, 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. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. 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. *

Full Name *

Name of guardian:

Reviewed by Treating Dentist

PATIENT PRIVACY CONSENT: Privacy to your personal information is an essential part of our office providing you with quality care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients. All staff members who encounter your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Date *

Please sign this consent form, we have outlined what our office is doing to ensure that: • Only necessary information is collected about you • We only share your information with your consent • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protocols • Our privacy protocols comply with privacy legislation, standards of our regulatory body and the law Do not hesitate to discuss our policies with me or any member of our office staff. Please be assured that every staff person in our office is committed to ensuring that you receive the best quality care.

MEDICAL INFORMATION:

HEALTH HISTORY:

Women Only:

Dental History