New Patient Form

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PATIENT INFORMATION (Confidential)

Name

First

Last

Birth Date

Address

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Employer

Marital Status

Gender

EmergencyContact/Parent Contact

Emergency Phone

Do you have secondary insurance?

PATIENT MEDICAL HISTORY

Physician

Physician's Office Phone

Are you currently experiencing any dental issues?

Are you currently under any medical treatment?

Have you been admitted to a hospital or needed emergency care during the past two years?

Are you currently taking any medications, including over the counter medications?

Have you ever had any complications following dental treatment?

Are there any conditions or diseases not listed above that you have or ever had?

Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)

Do you have a history of snoring/sleep apnea?

WOMEN ONLY: Are you breast feeding?

WOMEN ONLY: Are you pregnant?

Do you have any allergies to medications?

PERSONAL HISTORY

Are you fearful of dental treatment?

Have you had an unfavorable dental experience?

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Did you ever have braces, orthodontic treatment, or had your bite adjusted?

Have you had any teeth removed or missing teeth that never developed?

GUM AND BONE

Do your gums bleed or are they painful when brushing or flossing?

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Have you ever noticed an unpleasant taste or odor in your mouth?

Is there anyone with a history of periodontal disease in your family?

Have you ever experienced gum recession?

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Have you experienced a burning or painful sensation in your mouth not related to your teeth?

TOOTH STRUCTURE

Have you had any cavities within the past 3 years?

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

Do you have grooves or notches on your teeth near the gum line?

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

Do you frequently get food caught between any teeth?

BITE AND JAW JOINT

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Do you feel like your lower jaw is being pushed back when you bite your teeth together?

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Are your teeth becoming more crooked, crowded, or overlapped?

Are your teeth developing spaces or becoming more loose?

Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

Do you place your tongue between your teeth or close your teeth against your tongue?

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Do you clench your teeth in the daytime or make them sore?

Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?

Do you wear or have you ever worn a bite appliance?

SMILE CHARACTERISTICS

Is there anything about the appearance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Are you a sedation patient or interested in sedation?

CANCELLATION POLICY

Signature (Cancellation Policy)

Clear Signature

At DentiFlow Dental Clinic, all efforts will be made to accommodate your schedule. If you need to make any changes to your appointment we ask that you provide us with 2 business days' advance notice. This courtesy on your part will allow us to arrange for the time that was initially reserved just for you to be given to another patient that is in need of care. Failure to provide notice may result in a minimum charge of $50 to your account.

Our team will make every effort to ensure that we are on time for you! We expect that you will make the same effort and ensure that you are on time for your appointment. Be there a few minutes early to update your medical, insurance, and contact information. Please be aware that if you are late for a scheduled appointment, we may need to reschedule you to ensure that our patients who arrive on time are seen on time.

I have read and understand the above cancellation policy.

Are you a?

Patient
Parent
Guardian

Date

Signature (Consent for services)

Clear Signature

I, the 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. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for the payment for the dental services provided for myself and dependents is mine, and I will assume responsibility for fees associated with these services.