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Legal Name

Preferred Name

Best Contact Phone Number

Address

Alternate Phone Number

City

Date of Birth

Province

Email

Postal Code

Would you like to receive correspondence by email?

Yes
No

If a minor, please enter parent's name:

Who can we thank for referring you to our practice?

Who can we contact in case of an emergency?

Emergency phone number:

APPOINTMENTS:
Appointment times are reserved for you. If you are unable to keep an appointment please allow two business days notice to avoid a late-cancellation or missed appointment fee ($100/hour)

PERMISSION TO TREAT:
This is to certify that I, the undersigned, consent to the performing of dental and oral surgery procedures that are necessary or advisable, including the use of local anesthesia. I authorize the release of any records that are relevant to the processing and payment of this claim held by the service provider, any appropriate health professional licensing or regulatory body for the purpose of administrative audit.

Dental Insurance

In order to prevent any misunderstanding about your dental insurance, please note that all professional services provided are the financial responsibility of the patient or legal guardian. Full payment is due when services are rendered unless financial arrangements are made ahead of time. With your permission, we can contact your insurance provider on your behalf to determine eligibility and benefits.

Do you have dental insurance?

Yes
No

Dental information and history

Who was your previous dentist?

How long since your last dental visit?

What was done at that time?

Are you having any problems with your teeth at this time?

Please describe what you would like to achieve

Are you interested in Invisalign, whitening, veneers, Botox or any of our other cosmetic services?

Yes
No

Have you ever been told that you have gum disease?

No
Yes

Medical Information

Name of your physician

Date of your last physical

Are you taking any medications?

Yes
No

Please list what medications you are taking

Are you allergic to any medications?

Yes
No

Please list the medication's you're allergic to

Do you smoke?

Yes
No

How much do you smoke per day?

Do you use cannabis?

Yes
No

Are you allergic to latex?

Yes
No

Do you or have you ever had any of the following:

Heart Condition

Yes
No

Please describe your heart condition

Respiratory Illness

Yes
No

Please describe your respiratory illness

Artificial Heart Valve, Damaged Valve, or Pacemaker

Yes
No

Please elaboraster on your Artificial Heart Valve, Damaged Valve, or Pacemaker

Heart murmur that require antibiotic for dental visits

Yes
No

Postive HIV test

Yes
No

Cancer

Yes
No

Hepatitis

None
A
B

Chemotherapy or Radiation

Yes
No

Tuberculosis

Yes
No

Blood Pressure

Yes
No

Diabetes

Yes
No

Diabetes

Yes
No

Fainting Spells

Yes
No

Abnormal Bleeding

Yes
No

If you're a woman, are you pregnant

Yes
No

Do you have any other medical condition that we should be aware of?

Please type your full legal name to indicate that you have read and agree with the above

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Patient Intake Form

Dental Insurance

Dental information and history

Medical Information

Do you or have you ever had any of the following: