New Patients Form

New Patient Forms

Welcome to Nordic Dentistry! To help make your first visit as smooth as possible, we ask all new patients to complete our new patient forms before their appointment. Filling out our new patient forms in advance saves you time in the waiting room and allows our team to better understand your dental history, insurance details, and any concerns you’d like to discuss with the dentist.

You can complete our new patient forms securely online using the form below. If you would prefer to fill out our new patient forms in person, simply arrive 10-15 minutes early for your appointment and our front-desk staff will be happy to assist you.

New Patients Form

Title:

Mr.MrsMsMissDr

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)

Why We Ask New Patients to Complete These Forms

Our new patient forms gather important information about your medical and dental history, current medications, allergies, and insurance coverage. This helps our dentists and hygienists provide safe, personalized care tailored to your needs from your very first visit. Completing our new patient forms ahead of time also helps us verify your insurance benefits before you arrive, so there are no surprises about coverage or cost.

Frequently Asked Questions

How long does it take to complete the new patient forms? Most patients finish our new patient forms in about 10 to 15 minutes.

Do I need to bring anything else to my first appointment? Please bring a valid photo ID and your dental insurance card, in addition to submitting your new patient forms online.

What if I have questions while filling out the new patient forms? Feel free to call our office at (519) 208-4060, and our team will be happy to help you complete your new patient forms over the phone.

What to Bring to Your First Visit

In addition to completing our new patient forms, please bring a valid photo ID, your dental insurance card, and a list of any current medications. Arriving with your new patient forms already submitted helps our Kitchener office run on time and gives our front-desk team a chance to review your details before you sit down in the chair. If you have children joining the practice, a parent or guardian should complete the new patient forms on their behalf, including any history of orthodontic work or allergies to local anesthetics.

Secure and Confidential

All information submitted through our new patient forms is stored securely and only used by our clinical team to prepare for your visit. We never share your details with third parties. Nordic Dentistry is proud to serve families across Kitchener, Waterloo, and the surrounding region, and our new patient forms are the first step toward building a long-term relationship with a dental home you can trust. If you have any trouble accessing the form below, simply call our office and a member of our team will walk you through the new patient forms over the phone or email a printable copy for you to bring to your appointment.

Getting Started With Nordic Dentistry

Our team looks forward to welcoming you as part of the practice family. Once your paperwork is on file, our front-desk coordinators will confirm your appointment time and answer any last-minute questions about parking, arrival time, or what to expect during your first exam. Many patients tell us the online process took only a few minutes and made check-in on the day of their visit much faster.

We also encourage returning patients to update their file whenever their health history, medications, or insurance provider changes, so our clinical team always has the most accurate picture of your care needs. Keeping this information current helps us plan treatment safely and avoid delays at your next checkup. If anything is unclear while filling things out, our Kitchener office is always just a phone call away.