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New Patients Form
Title:
Mr.
Mrs
Ms
Miss
Dr
First Name:
(Required)
Last Name:
(Required)
How did you find us
(Required)
GOOGLE - Internet
Website
Social Media
Radio
Other
DATE OF BIRTH (D/M/Y):
(Required)
DD slash MM slash YYYY
Age:
Gender
Male
Female
Phone (Home)
Phone (Cell)
Phone (Work)
Home Address:
(Required)
City :
(Required)
App/Unit
Province:
(Required)
Postal Code:
(Required)
Email
Occupation:
Employer:
Health card number:
Name of Family Doctor:
Phone:
Address:
Name of your Specialist:
Phone:
Address:
In case of EMERGENCY, We should notify:
Name:
Relationship:
Phone:
Insurance Information
Primary Insurance Company Information
Name of Insurance Policy Holder:
Date of Birth:
DD slash MM slash YYYY
Policy holder Contact Phone Number:
Group Policy/plan Number:
I.D./Certificate Number:
Marital Status:
Single
Married/Common Law
Other
Insurance Company Name:
Secondary Insurance Company Information
Name of Insurance Policy Holder:
Date of Birth:
DD slash MM slash YYYY
Policy holder Contact Phone Number:
Group Policy/plan Number:
I.D./Certificate Number:
Marital Status:
Single
Married/Common Law
Other
Insurance Company Name:
Medical History
The following information is required to enable us to provide you with the best possible dental care. All information in the medical and dental history 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 fill in the entire form.
Do you have or have you ever had any of the following:
Heart condition
Angina (Chest Pain)
Heart surgery/procedures
Heart attack
Stroke/T.I.A
Heart murmur
Mitral valve prolapse
Congenital heart disease
Infective Endocarditis
Pacemaker
High blood pressure
Low blood pressure
General Anesthetic complications
Diabetes: Type l or ll
Hypolglycemia
Rheumatic fever
HIV positive/AIDS
Leukemia
Anemia
Blood disorders
Hepatitis A/B/C
Hemophilia
Excessive bleeding/bruising
Immunedeficiencies
Eating disorder
Lupus
Thyroid disease
Kidney disease
Liver disease
HPV
Herpes/Cold sores
Physical impairment
Cancer
Asthma
Respiratory conditions
Lung disease
Tuberculosis
Snoring/sleep apnea
Dizziness/fainting
Ulcers/acid reflux
Intestinal/stomach problems
Above average weight gain/loss
COVID-19
Vision Impairment
Hearing impairment
TMJ (jaw joint) concerns
Arthritis
Joint Replacement
Osteoperosis
Epilepsy/seizures
Cognitive impairment
Depression
Anxiety
Mental health issues
Drug/alcohol dependency
Tobacco Use
Other
Are there any conditions or diseases not listed above that you have or have had?
Yes
No
Not Sure
Please explain
Do you have any allergies or sensitivities to any:
Medications:
Latex/rubber products:
Other: (e .g . hay fever, seasonal/environmental, foods):
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Yes
No
Not Sure
please list them:
Has your physician ever told you to take antibiotics prior to dental procdure?
Yes
No
Not Sure
please mention the reason for antibiotic:
Have you ever experienced complications following a medical or dental procedure?
Yes
No
Are you currently being treated for any medical condition or have you been treated within the past year?
Yes
No
Not Sure
please explain?
Do you have or have you ever had a replacement or repair of a heart valve, an 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
please explain:
Have you ever been hospitalized for any illnesses or operations?
Yes
No
please explain:
Do you identify as a patient with a disability?
Yes
No
Are you Pregnant?
Yes
No
Not Sure
what is the expected delivery date?
Are you breastfeeding?
Yes
No
Do you smoke or chew tobacco products?
Yes
No
Has there been any change in your general health in the past year?
Yes
No
please explain:
To the best of my knowledge, the above information is correct.
Patient/Parent/Guardian Signature:
(Required)
Date
DD slash MM slash YYYY
Dentist Notes:
Dental History Questionnaire
1 . What is the reason for your visit today? Are you currently experiencing any dental problems?
2 . Have you been seeing a dentist regularly?
Yes
No
why not?
3 . Are you nervous during dental visits?
Yes
No
4 . Have you had a bad experience or complications during dental treatment?
Yes
No
5.1. When was your last dental visit?
5.2. What was done at that appointment?
6.1. How often do you brush your teeth?
6.2. How often do you floss?
7. Do your gums bleed when you brush or floss?
Yes
No
Not Sure
8 . Do you feel that you have bad breath?
Yes
No
Not Sure
9 . Are you happy with the appearance of your teeth?
Yes
No
10 . Are you happy with your smile?
Yes
No
11.1. Have you ever whitened your teeth?
Yes
No
11.2. Are you interested in whitening?
Yes
No
12 . Is there anything about the appearance of your teeth that you would like to change?
Yes
No
please explain:
13 . Are you self conscious about your teeth?
Yes
No
14 . Do you have any problems with your jaw (clicking, limited movement, pain)?
Yes
No
Not Sure
15 . Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?
Yes
No
16 . What is the most important thing to you about your future smile and dental health?
Patient/Parent/Guardian Signature:
(Required)
Date
(Required)
DD slash MM slash YYYY
Privacy Consent
I allow and provide consent to Nordic Dentistry to collect, use and disclose information about me for the following purposes:
To deliver safe and efficient patient care
To identify and to ensure continuous, high-quality services
To assess my dental health needs
To advise me of treatment options
To enable Nordic Dentistry to contact me directly
To establish and maintain communication with me
To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care
To allow Nordic Dentistry to efficiently follow-up for treatment, care, and billing For teaching and demonstrating purposes on an anonymous basis
To complete and submit electronic and/or paper dental claims for third party adjudication, pre-approval where necessary, and payment
To permit dentists, practice brokers and/or advisors to evaluate the dental practice and conduct an audit in preparation for practice sale
To invoice for goods and services
To process credit card payments when there is a balance outstanding or when I call in and provide telephone authorization
To provide Nordic Dentistry with insurance details, so we may receive a dental breakdown of the coverage. You are also responsible for any differences not paid by the insurance company, on the same day as the service is rendered.
o If a patient’s account falls into arrears all reasonable collection fees will be the responsibility of the account holder, in addition to the arrears and possible service fee.
I authorize Nordic Dentistry to post/advertise pictures within the office and on social media of myself or my child/dependent.
I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.
This authorization shall continue in effect until authorize the communication of information related to the coverage of services described to the named dentist.
Agree
(Required)
Agree To Privacy
Name
(Required)
First
Last
Signature
(Required)
