PERSONAL INFORMATION

Date: Status: ---SingleMarriedSeparatedDivorcedWidowed Prefix: ---MrMrsMsMissDr

Given Name:  

Family Name:

Address: Apt:
City: Province: Postal Code:

Date of Birth:

Telephone Residence:

Telephone Business: Ext.

Occupation: Referred By:

Person responsible for account:
SelfOther

Dental Insurance: NoYes.

Name of Insurance Company:

Reason for today’s visit:
ExaminationEmergencyOther

Physician Name:

In case of emergency please notify:
Name: Relationship:

Telephone:

MEDICAL HISTORY

The following information is required by the dentist to assist in proper diagnosis and treatment. All information is confidential.

1. Are you presently under the care of a physician? YesNo

2. Have you ever been hospitalized? YesNo
Specify:

3. Do you have a heart or circulatory problem of any kind? YesNo

Please List Heart or Circulatory Problems Here

4. Have you ever had rheumatic fever? YesNo

5. Do you have any allergies? YesNo,
Specify

6. Are you presently taking any kind of medication? YesNo

Please list medications and reasons for taking here

7. Do you have bleeding problems? YesNo

8. Are you pregnant? YesNo

9. Have you ever had a reaction to any knd of medicine? YesNo ,
Specify:

10. Do you presently or have you ever had (Hold CTRL to make multiple selections):

AnaemiaArthritisAsthmaBlood disorderDiabetesEpilepsyHay feverHemorrhageHigh (Low) blood pressureHyper (Hypo) glycemiaLivery disease (e.g. Hepatitis)Lung diseaseMental or nervous disorderMigraine headachesRheumatismScarlet feverStomach (intestinal) ulcerThyroid problemTuberculosisVenereal diseaseHIV

11. Have you ever had concussion? YesNo

12. Have you ever fainted? YesNo

13. have you ever had any illness not included above? YesNo

14. have you ever had local anaesthetic? YesNo

PATIENT CERTIFICATION AND APPROVAL
I, the undersigned certify the all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

Patient (Parent, Guardian) Signature , Date:

PATIENT (GUARDIAN) CONSENT (FOR MINORS)
I, the undersigned, consent to the performing of dental and oral surgery procedures agree to be necessary or advisable, including the use of local unaesthetic as indicated, and I will assume responsibility for fees associated with these procedures.

Parent (Guardian) Signature , Date:

Your Email (required)