905 840 8372 | info@lormelgatedentistry.com   

New Patient Form

Welcome to our office! To assist us in serving you, please complete the following confidential form.
The information provided is important to your dental health.

Patient's name If minor, parents names Mailing address PC Spouse's name
Preferred name Home Phone City Employer Spouse's employer
Birth date Work phone Prov Occupation Unmarried

Whom may we thank for referring you to our office

Phonebook

BILLING, CREDIT, AND INSURANCE INFORMATION:

Not covered by dental insurance

Health Card number:
Dental Insurance Co
Group number

Covered by spouse’s insurance?
Yes    No

Spouse's dental insurance company
Group number
Spouse's birthday

MEDICAL HEALTH HISTORY

Do you have or have you had any of the following?
(Please check any that apply)

Cancer or tumor
Heart ailment or angina
Heart murmur, mitral valve prolapse, heart defect
Rheumatic fever or rheumatic heart disease
Artificial joint or valve
High or low blood pressure
Pacemaker
Tuberculosis or other lung problems
Kidney disease
Hepatitis or other liver disease
Alcoholism
Blood transfusion
Diabetes
Neurologic condition
Epilepsy, seizures, or fainting spells
Emotional condition
Arthritis
Herpes or cold sores
AIDS or HIV positive
Migraine headaches or frequent headaches
Anemia or blood disorders
Abnormal bleeding after extractions, surgery, or trauma
Hayfever or sinus trouble
Allergies or hives
Asthma

Do you smoke or use chewing tobacco? Yes     No
Are you allergic to, or have you reacted adversely to any of the following?

Latex materials
Penicillin or other antibiotics
Local anesthetics ("Novocain")
Codeine or other narcotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin
Other
Are you taking any of the following?

Aspirin
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Insulin, Orinase, or other diabetes drug
Nitroglycerin
Cortisone or other steroids
Osteoporosis (bone density) medicine
Other

Women
May be pregnant
Expected delivery date:

Taking hormones or contraceptives



Name of your physician Do you have any disease, condition, or problem not listed above? Please add anything else you would like us to know about

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