New Patient Form

The information in this questionnaire is CONFIDENTIAL.

This information assists in proper diagnosis and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible, they will be reviewed at your first appointment. We ask that you fill this out at least 48 hours prior to your schedule appointment. Thank you.

PATIENT CONTACT INFORMATION

Title

Mr Mrs Ms Miss Dr

Pronouns

Full Name

Preferred Name

Date of Birth

Gender

Male Female Non-Binary Other

Full Address. Please include Street, Number, City, Postal Code and Province.

Home Phone Number

Marital Status

Single Married Common Law Widowed

Employer

Cell Phone Number

Email address

In case of Emergency, please contact

Include name and number for contact

What is the best way to contact you?

Email Home Cell

What is the best time to contact you?

Morning Afternoon Evening

REFERRAL INFORMATION

Name of personal referral if applicable

INSURANCE INFORMATION

Do you have an insurance plan with dental coverage?

Yes No

Primary Insurance Information

Insurance Policy Holder:

Self Spouse Parent/Guardian

Name of Insurance Policy Holder

Date of Birth of Insurance Policy Holder

Insurance Company Name

Group Plan/Policy Number:

ID/Certificate Number:

Secondary Insurance Information

Insurance Policy Holder:

Self Spouse Parent/Guardian

Name of Insurance Policy Holder

Date of Birth of Insurance Policy Holder

Insurance Company Name

Group Plan/Policy Number:

ID/Certificate Number:

DENTAL HISTORY

Date of last dental visit:

If unsure, choose today’s date

Date of last dental cleaning:

If unsure, choose today’s date

Date of last dental x-rays:

If unsure, choose today’s date

Do you smoke, vape or chew tobacco?

Yes No Other

If yes, how often and for how long?

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

Dentures or Partial Dentures

Implants

Braces

Periodontal (gum) Disease

Difficult Extractions

None of the Above

Do you currently have a general dentist?

Yes No

If yes, what is their name?

If no, would you like a dentist referral?

Is there anything else about your teeth you would like us to know?

MEDICAL HISTORY

If you answered yes or other to any of the above conditions, please explain:

Do you have any of the following allergies?

Antibiotics

Latex

Nuts

Food Colouring

Other

None

Do you currently have, or have you ever had in the past, a disease, condition or problem not listed above?

Yes No

If yes, please explain:

Have you been hospitalized for illness or surgery in the past 2 years?

Yes No

If yes, please explain:

Have you ever had a joint replacement?

Yes No

If yes, when?

Has your physician ever told you to take antibiotics prior to dental procedures?

Yes No

If yes, why?

Have you ever experienced complications following a medical or dental procedure?

Yes No

If yes, specify why:

Is there anything else you think we should know regarding your medical history?

Yes No

If yes, please describe:

Are you taking any medications?

Yes No

If yes, please list medications, dosages & the reason for each:

What is your most recent blood pressure reading?

systolic/diastolic

If you are diabetic, what is your most recent A1C test results?

Do you have a family doctor?

Yes No

Physician and Contact Number

Are you under the care of a specialist?

Yes No

Specialist Name and Number

WOMEN ONLY

Are you pregnant or suspect you may be?

Yes No Unsure

Are you taking birth control (pills or other method)?

Yes No

Are you aware of your bone mineral density?

Yes No

To be filled out in office

PRIVACY AND CONSENT INFORMATION

This information has been reviewed with me. I agree that personal information may be collected, used and disclosed as set out in the Privacy Policy of this dental hygiene office in accordance with the Personal Health Information Protection Act, 2004. A full copy of the privacy policy and consent form is available should I choose to view. I understand that I am financially responsible to the hygienist for the dental hygiene services provided.

Consent for Collection, Use and Disclosure of Personal Information

I agree that Calabogie Smiles Dental Hygiene obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. If required, I consent to my physician being contacted regarding any specific medical question relevant to my dental hygiene care. I authorize the dental hygienist and her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental hygiene care.

Today's Date

Parent/Guardian Name: (Only if the Patient is under 18)

I certify that I have read, understood and accurately completed the personal, medical, and dental histories to the best of my knowledge and have not knowingly omitted any information. I understand that I am financially responsible to the hygienist for the dental hygiene services provided.

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