Patient Registration Form Patient Information *All fields requiredDate* MM slash DD slash YYYY Salutation*Mr.Mrs.Ms.Dr.First Name* Last Name* Date of Birth* MM slash DD slash YYYY Spouse Name* Registering for a child?* Yes No Occupation Alberta Healthcare NumberSINPerson responsible for account* Other parental consent required* Yes No Mother’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* Phone SMS (TEXT) Email How did you hear about our office? Whom may we thank for referring you?* Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment* Insurance Company* Policy/Group #* Certificate/ID #* Do you have more than one insurance policy? Yes No Please complete the following if you have more than one dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place 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?* Yes No Not Sure/Maybe When was your last medical checkup?* MM slash DD slash YYYY Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please 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?* Yes No Not 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?* Yes No Not Sure/Maybe Please list medication with approximate date and explain the reaction.*Do you have or have you ever had asthma?* Yes No Not Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe Do 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?* Yes No Not Sure/Maybe Do you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe Please specify*Have you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe Do you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe Please specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please 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?* Yes No Not Sure/Maybe If yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Are you nervous during dental treatment?* Yes No Not Sure/Maybe For women only: Are you pregnant or breastfeeding?* Yes No Not Sure/Maybe What is your expected delivery date?* MM slash DD slash YYYY Is there any other information regarding your health which was not covered above?* Yes No Not sure/Maybe Please 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?* MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Do you have any sore, aching, sensitive, or loose teeth? Yes No Maybe/Unsure Do you or have you ever had any jaw joint (TMJ) problems, or any oral habits such as clenching, grinding or nail biting? Yes No Maybe/Unsure Do you have or have you ever had an occlusal splint (night guard) Yes No Maybe/Unsure Is there anything about the appearance of your teeth that you would like to change?*Have you ever whitened (bleached) your teeth? Yes No Not Sure/Maybe Do 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.
