Patient Registration Form Patient Information *All fields requiredFirst Name* Last Name* Date of Birth* MM slash DD slash YYYY Registering for a child?* Yes No Person responsible for account* Other parental consent required* Yes No Mother’s name* Business Tel*Father’s name* Business Tel*Contact InformationEmail* Home PhoneCell Phone*Work PhoneAddress* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code In case of emergency, please notify:Name* Relation* Home PhoneCell Phone*Work PhoneContact OptionsI prefer appointment reminders by* Phone SMS (TEXT) Email Whom may we thank for referring you? Are any other members of your family patients at our practice?* Yes No Please list all family members*Insurance InformationDo you have insurance?* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment* Insurance Company* Policy/Group #* Certificate/ID #* Do you have a second insurance?* Yes No Second Insurance - Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of Employment* Insurance Company* Policy/Group #* Certificate/ID #* I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Medical History The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?* Yes No Not Sure/Maybe When was your last medical checkup?* MM slash DD slash YYYY Has there been any change in your general health in the past year?* Yes No Not Sure/Maybe Please Specify*Are you taking any prescription, non-prescription medications, or herbal supplements?* Yes No Not Sure/Maybe Please list and provide dosages. If there is insufficient room, please bring a written list of all your medications to your first appointment.*HiddenDo you have any allergies?* Yes No Not Sure/Maybe Hidden--select--*MedicationsLatex/Rubber ProductsOther (e.g hayfever, foods, etc)Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Not Sure/Maybe Please list below with approximate dates* MM slash DD slash YYYY HiddenDo you have or have you ever had asthma?* Yes No Not Sure/Maybe Do you have or have you ever had any heart or blood pressure problems?* Yes No Not Sure/Maybe HiddenDo you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?* Yes No Not Sure/Maybe HiddenDo you have a prosthetic or artificial joint?* Yes No Not Sure/Maybe HiddenDo you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Not Sure/Maybe HiddenPlease specify*HiddenHave you ever had hepatitis, jaundice, or liver disease?* Yes No Not Sure/Maybe HiddenDo you have a bleeding problem or bleeding disorder?* Yes No Not Sure/Maybe HiddenPlease specify*Have you ever been hospitalized for any illnesses or operations?* Yes No Not Sure/Maybe Please specify*Do you have, or have ever had any of the following? Please check* AIDS Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Hear Murmur Hepatitis High Blood Pressure Liver Disease Mental Illness Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems Rheumatic Fever Venereal Disease Sinus Problems Stomach Problems None of the Above Stroke Tuberculosis Other Tumours Ulcers If Other please specify*HiddenAre there any conditions/diseases not listed that you have or have had?* Yes No Not Sure/Maybe HiddenIf yes, please specify:*Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?* Yes No Not Sure/Maybe If yes, please specify:*Do you smoke or chew tobacco products?* Yes No Not Sure/Maybe Are you nervous during dental treatment?* Yes No Not Sure/Maybe If yes, please specify:*For women only: Are you pregnant or breastfeeding?* Yes No Not Sure/Maybe If yes, please specify:*What is your expected delivery date?* MM slash DD slash YYYY Have you had the Gardasil 9 Vaccine? (For head and neck cancer)* Yes No Dental HistoryDo you have any specific dental concerns? Please list:When was your last dental appointment? MM slash DD slash YYYY How often do you see the dentist?* Not Applicable Every 3 months Every 4 months Every 6 months Only when something is bothering me Is there anything about the appearance of your teeth that you would like to change?Have you ever whitened (bleached) your teeth?* Yes No Not Sure/Maybe Do you feel uncomfortable or self-conscious about the appearance of your teeth? Have you been disappointed with the appearance of previous dental work? To the best knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail. Consent For Services All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed. The office reserves the right to refuse the use of personal cheques as a form of payment for these appointments unless prior approval from the dentist. In consideration for the professional services rendered to me or at my request by the Doctor, I agree to pay for services to said Doctor, at the time services, are rendered. This is to certify that, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures. I consent to the collection, retention, use and disclosure of personal information as required for my dental care.Signature of patient, parent or guardian*Date* MM slash DD slash YYYY Doctor's Signature (For Office Use)Date (For Office Use) MM slash DD slash YYYY I agree to receive emails with related information and updates. 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