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In order to render an optimum health service it is necessary to obtain a variety of vital personal information. All information obtained is of course confidential.

Name:
Age:
Birthdate:
Home Address:
Postal Code:
Phone:
Status:	Single Married Separated Divorced Widow(er)
Occupation:
Employer:
Business Address:
Business Phone:
Referred to this office by:
Immediate family members name:
Person responsible for this account:
Dental Insurance:	Yes No
Name of Insurance Carrier:
Policy Number:
Address:
SIN Number:
Medical History:
Name of Physician:
Phone:
Address:
Note:If you are unsure of any of the following questions, please mark them and ask the doctor for an explanation.

Check One

Yes

Not Sure

Have you been a patient in a hospital or under the care of a physician during the past 2 years?

Have you taken any kind of medicine or drugs during the past year?

If yes, please list them:

Are you allergic to penicillin, aspirin, codeine, local anaesthetics, or other drugs?

If yes, specify:

Do you ever have chest pains or shortness of breath?

Do you smoke tobacco?

Have you ever experienced any excessive bleeding that required special treatment?

Do you have any artificial prosthetic valves or joints?

Have you any serious trouble associated with any previous dental treatment?

Do you require prophylatic antibiotics prior to dental treatment?

10.

Have you had any of the following?

	Yes	No	Not Sure		Yes	No	Not Sure		Yes	No	Not Sure
heart trouble or lesions				kidney trouble				arthritis
malignant hyperthermia				asthma				scarlet fever
heart murmur				persistent cough				stroke
high blood pressure				diabetes				epilepsy
anemia				tuberculosis				sinus trouble
rheumatic fever				hepatitis				hay fever
venereal disease				jaundice				glaucoma
cold sores				mononucleosis				drug addiction
aids				thyroid problems

11.

Have you had any other serious illnesses?

12.

(Women) Are you pregnant now?


Dental History

Reason for dental appointment:
When was your last dental examination?
How often do you visit the dentist?
How often do you brush you teeth?
How often do you floss your teeth?

	Check One
	Yes	No
Do you frequently clench or grind your teeth?
Do you have pain in chewing?
Do you notice a clicking or cracking of the jaws in opening & closing?
Do you have any sores in your mouth?
Have you ever had a tooth extrated?
Were there any complications?
Do your gums bleed easily?
Are you aware of bad breath or taste in your mouth?
Has your dental work been done with the use of local anaesthetic?
Are you tense during dental visits?
Have you ever seen a periodontist for treatment?
Have you ever had orthodontic treatment?
Other:

Consent for Operations

This is to certify that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable and I will assume resposibilty for fees associated with those procedures.

Date: 04 September 2010

I authorize release, to my Insuring company plan administrator, the information contained in claims submitted electronically.

PLEASE NOTE

Your appointment time is especially reserved for you. If you cannot keep the appointment we require 24 hours notice. If we are not notified you will be charged for the lost time. Office policy is such that services are paid for at each visit as they are performed. However in special circumstances arrangements for payment can be made by consulting with the Doctor.