Patient Registration Form Patient Name :*Gender :* Male Female Martial Status :*--select--MarriedSingleChildOtherBirth Date :* Date Format: MM slash DD slash YYYY Email Address : Phone (Home) :Phone (Work) :Preferred appointment times:--select--MorningAfternoonEveningAnytimeBest Time To Call :--select--MondayTuesdayWednesdayThursdayFridayAddress : Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Health Information Date of Last Dental Visit : Date Format: MM slash DD slash YYYY Reason for this visit:Have you ever had any of the following? Please check those that apply : AIDS Allergies Arthritis Artificial Joints Asthma Blood Disease Cancer Codeine Allergy Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Heart Disease Heart Murmur Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Penicillin Allergy Pregnancy Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease other Height (m):Weight (kg):Please list all prescription and non-prescription medications:Have you ever had any complications following dental Treatment ? Yes No Please explain:Have you been admitted to a hospital or needed emergency care during the past two years ? Yes No Please explain:Are you now under the care of a physician ? Yes No Please explain:Name of the physician:PhoneDo you have any health problems that need further clarification? Yes No Please explain :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.Date : Date Format: MM slash DD slash YYYY Signature of patient, parent or guardianConsent for Services All emergency dental service, 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. Date Date Format: MM slash DD slash YYYY Patient's SignatureParent's Signature (If patient is under 18)Parent's Name :ContactEmergency ContactRate your smile :--select--12345678910Have you ever thought of bleaching your teeth?Intial ShadeAre comfortable with the alignment of your teeth?Classification 1 2 3 Dental HistoryNameNicknameAgeReferred byHow would you rate your mouth? Excellent Good Fair Poor Previous DentistHow long have you been a patient ? (Months/Years)Date of most recent dental exam Date Format: MM slash DD slash YYYY Date of most recent X-rays Date Format: MM slash DD slash YYYY Date of most recent treatment (other than cleaning) Date Format: MM slash DD slash YYYY I routinely see my dentist every:--select--3 months4 months6 months12 monthsNot routinelyWhat is your immediate concern?PLEASE ANSWER YES OR NO TO THE FOLLOWING: PERSONAL HISTORYAre you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) Yes No Please explain:Have you had an unfavorable dental experience? Yes No Please explain:Have you ever had complications from past dental treatment? Yes No Please explain:Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes No Please explain:Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? Yes No Please explain:Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No Please explain:GUM AND BONEDo your gums bleed or are they painful when brushing or flossing? Yes No Please explain:Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No Please explain:Have you ever noticed an unpleasant taste or odor in your mouth? Yes No Please explain:Is there anyone with a history of periodontal disease in your family? Yes No Please explain:Have you ever experienced gum recession? Yes No Please explain:Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No Please explain:Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes No Please explain:TOOTH STRUCTUREHave you had any cavities within the past 3 years? Yes No Please explain:Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No Please explain:Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? Yes No Please explain:Do you have grooves or notches on your teeth near the gum line? Yes No Please explain:Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No Please explain:Doyoufrequently get food caught between any teeth? Yes No Please explain:BITE AND JAW JOINTDo you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No Please explain:Do you feel like your lower jaw is being pushed back when you bite your back teeth together? Yes No Please explain:Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No Please explain:In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed? Yes No Please explain:Are your teeth developing spaces or becoming more loose? Yes No Please explain:Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes No Please explain:Do you place your tongue between your teeth or close your teeth against your tongue? Yes No Please explain:Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No Please explain:Do you clench or grind your teeth together in the daytime or make them sore? Yes No Please explain:Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? Yes No Please explain:Do you wear or have you ever worn a bite appliance? Yes No Please explain:SMILE CHARACTERISTICSIs there anything about the appearance of your teeth that you would like to change (shape, color, size)? Yes No Please explain:Have you ever whitened (bleached) your teeth? Yes No Please explain:Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes No Please explain:Have you been disappointed with the appearance of previous dental work? Yes No Please explain:Patient's SignatureDate Date Format: MM slash DD slash YYYY Doctors SignatureDate Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.