PERSONAL INFORMATION
Date: Status: --- Single Married Separated Divorced Widowed Prefix: --- Mr Mrs Ms Miss Dr
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: Self Other
Dental Insurance: No Yes .
Name of Insurance Company:
Reason for today’s visit: Examination Emergency Other
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? Yes No
2. Have you ever been hospitalized? Yes No
Specify:
3. Do you have a heart or circulatory problem of any kind? Yes No
4. Have you ever had rheumatic fever? Yes No
5. Do you have any allergies? Yes No ,
Specify
6. Are you presently taking any kind of medication? Yes No
7. Do you have bleeding problems? Yes No
8. Are you pregnant? Yes No
9. Have you ever had a reaction to any knd of medicine? Yes No ,
Specify:
10. Do you presently or have you ever had (Hold CTRL to make multiple selections):
11. Have you ever had concussion? Yes No
12. Have you ever fainted? Yes No
13. have you ever had any illness not included above? Yes No
14. have you ever had local anaesthetic? Yes No
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)