905 840 8372 | firstname.lastname@example.org
Area of Practice
Surgically Clean Air
New Patient Form
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.
If minor, parents names
Whom may we thank for referring you to our office
BILLING, CREDIT, AND INSURANCE INFORMATION:
Not covered by dental insurance
Health Card number:
Dental Insurance Co
Covered by spouse’s insurance?
Spouse's dental insurance company
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
Tuberculosis or other lung problems
Hepatitis or other liver disease
Epilepsy, seizures, or fainting spells
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
Do you smoke or use chewing tobacco?
Are you allergic to, or have you reacted adversely to any of the following?
Penicillin or other antibiotics
Local anesthetics ("Novocain")
Codeine or other narcotics
Barbiturates, sedatives, or sleeping pills
Are you taking any of the following?
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Insulin, Orinase, or other diabetes drug
Cortisone or other steroids
Osteoporosis (bone density) medicine
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
Call us for Free Consultation
Feeling Social ? Connect us :
10 Lormel Gate, Unit 1
Brampton, ON. L7A 2K7
T : 905 840 8372 | F : 905 840 8373