Patient Registration Form Patient Information *All fields requiredDate* Date Format: MM slash DD slash YYYY Salutation*Mr.Mrs.Ms.Dr.First Name*Last Name*Date of Birth* Date Format: MM slash DD slash YYYY Spouse Name*Registering for a child?*YesNoOccupationAlberta Healthcare NumberSINPerson responsible for account*Other parental consent required*YesNoMother’s name*Business Tel*Father’s name*Business Tel*Contact InformationEmail* Home PhoneCell Phone*Work PhoneAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:Name*Relation*Home PhoneCell Phone*Work PhoneContact OptionsI prefer appointment reminders by*PhoneSMS (TEXT)EmailHow did you hear about our office?Whom may we thank for referring you?*Are any other members of your family patients at our practice?*YesNoPlease list all family members*Insurance Information*Yes, insurance applies to meNo, insurance does not apply to mePlease complete the following if you have dental insuranceName of insured/subscriber*Date of Birth* Date Format: MM slash DD slash YYYY Patient's relationship to subscriber*SelfSpouseChildPlace of Employment*Insurance Company*Policy/Group #*Certificate/ID #*Do you have more than one insurance policy?YesNoPlease complete the following if you have more than one dental insuranceName of insured/subscriber*Date of Birth* Date Format: MM slash DD slash YYYY Patient's relationship to subscriber*SelfSpouseChildPlace of Employment*Insurance Company*Policy/Group #*Certificate/ID #*I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Who is your Family Medical Doctor?Name:Phone:Are you being treated for any medical condition at the present or any time within the past year?*YesNoNot Sure/MaybeWhen was your last medical checkup?* Date Format: MM slash DD slash YYYY Has there been any change in your general health in the past year?*YesNoNot Sure/MaybePlease Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?*YesNoNot Sure/MaybePlease list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.Do you have any allergies?*YesNoNot Sure/Maybe--select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?*YesNoNot Sure/MaybePlease list medication with approximate date and explain the reaction.*Do you have or have you ever had asthma?*YesNoNot Sure/MaybeDo you have or have you ever had any heart or blood pressure problems?*YesNoNot Sure/MaybeDo you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?*YesNoNot Sure/MaybeDo you have a prosthetic or artificial joint?*YesNoNot Sure/MaybeDo you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*YesNoNot Sure/MaybePlease specify*Have you ever had hepatitis, jaundice, or liver disease?*YesNoNot Sure/MaybeDo you have a bleeding problem or bleeding disorder?*YesNoNot Sure/MaybePlease specify*Have you ever been hospitalized for any illnesses or operations?*YesNoNot Sure/MaybePlease specify*Do you have, or have ever had any of the following? Please check* Select All Chest pain/angina Osteoporosis Medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/Alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?*YesNoNot Sure/MaybeIf yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?*YesNoNot Sure/MaybeIf yes, please specify:*Do you smoke or chew tobacco products?*YesNoNot Sure/MaybeAre you nervous during dental treatment?*YesNoNot Sure/MaybeFor women only: Are you pregnant or breastfeeding?*YesNoNot Sure/MaybeWhat is your expected delivery date?* Date Format: MM slash DD slash YYYY Is there any other information regarding your health which was not covered above?*YesNoNot sure/MaybePlease specify:Dental History Please provide your Pharmacy informationName:Phone Number:Do you have any specific dental concerns? Please list:*Who was our previous Dentist?When was your last dental exam?* Date Format: MM slash DD slash YYYY How often do you see the dentist?*Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something is bothering meDo you have any sore, aching, sensitive, or loose teeth?YesNoMaybe/UnsureDo you or have you ever had any jaw joint (TMJ) problems, or any oral habits such as clenching, grinding or nail biting?YesNoMaybe/UnsureDo you have or have you ever had an occlusal splint (night guard)YesNoMaybe/UnsureIs there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth?YesNoNot Sure/MaybeDo you feel uncomfortable or self-conscious about the appearance of your teeth?*Have you been disappointed with the appearance of previous dental work? To the best of my knowledge, the above information is correct. I agree to receive emails with related information and updates.
