Welcome to Spring Garden Dentistry

PIPEDA

This act ensures that the privacy of your personal information is handled in a confidential manner by our office.

Patient Information

First name

Last name

Civic Address

Apartment Number

City

Postal Code

Home phone number

Cell phone number

Email address

Date of birth

NS Health Card number

Gender (as listed on your medical card)

Male

Female

Preferred Pronouns

Previous dentist

Who referred you to our office?

If you are a student who is still under their parents dental plan will complete the information below. If 21 and over please include the name of the school you are attending.

Parents name

Parents phone number

Address

Name of school

Insurance Information

Primary Insurance Information

Name of insurance company

Name of insurance policy holder

Policy holder's date of birth.

Gender listed on insurance forms.

Policy holder's employer

Group/Policy number

Id number

Relationship to policy holder

Dental History

Date of last dental visit

Date of last dental cleaning

Date of last dental x-rays

Please check any of the following problems that might apply to you

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding gums

Broken teeth or fillings

Headaches, earaches, or neck pain

Jaw joint pain

Sensitivity (hot, cold and/or sweet)

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

Dentures

Braces

Periodontal (gum) treatments

Difficult extractions

Do you have any dental fears?

Medical History

Name of your family doctor.

Are you pregnant?

Yes No

Have you ever been seriously ill, hospitalized or had surgery?

Yes No

If yes, what for.

If you checked "Other" please list your medical condition(s).

If you checked "Other" please list your allergies.

Please list any medications you may be on.

Prescription drugs and natural products.

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Emergency Contact Information

Add another emergency contact

Permission for Treatment & Promise of Payment

I consent to the performance of the specific procedures and treatments discussed and agreed upon with my provider. I also consent to the administration of necessary medications, including but not limited to anesthesia, pain management, or antibiotics, as deemed appropriate by my provider.

I understand that I am responsible for the payment of all fees associated with these procedures.

I consent

Cancellation Policy

Your appointment time is reserved for you. Kindly remember there will be a charge for cancellations made with less than 48 working hours notice, except when deemed by us to be reasonable and extenuating circumstances.

Your information will be encrypted.