Your cooperation in completing this questionnaire is essential to provide you with the best possible dental care.
All information is strictly confidential.

PATIENT INFORMATION
First Name:
Last Name:
Sex:
MaleFemale
Preferred Name:
Date Of Birth:
Street Address:
Street Address Line 2:
City:
Province:
Postal Code:
Phone:
Alternate Phone:
Email:
Family Physician's Name:
Office Name:
Legal Guardian (if patient is under 18)
First Name:
Last Name:
How did you hear about us?
ReferralTVInternetPrintOther
Other Please Specify
EMERGENCY CONTACT
Emergency Contact Name:
Relationship:
Phone:
Alternate Phone:
Email:
INSURANCE INFORMATION
If you have insurance, please complete the following information:
Policy Holder First Name:
Policy Holder Last Name:
Policy Holder Date Of Birth:
Insurance company:
ID or Certificate Number:
Group, Plan or Policy Number:


If you have a secondary insurance, please complete the following information:
Policy Holder First Name:
Policy Holder Last Name:
Policy Holder Date Of Birth:
Insurance Company:
ID or Certificate Number:
Group, Plan or Policy Number:
DENTAL INFORMATION
General Dentist:
Office Name:
Date of last dental visit:
Do you feel any pain or discomfort in your mouth/jaw joint:
YesNo
Have you had:
Orthodontic TreatmentPeriodontal ( Gum ) TreatmentJaw Joint Surgery
Do you have dental implants?
YesNo
Do you wear dentures/partial dentures?
YesNo
Please list any other information that you feel we should be aware of:
MEDICAL HISTORY
Are you taking any medications, pills, or drugs?
YesNo
If yes, Please specify:
Do you have any allergies?
YesNo
If yes, Please specify:
Have you had any adverse reaction to medications or dental local anesthetic?
YesNo
If yes, Please specify:
Have you ever had a heart valve repair/replacement or a heart condition from birth?
YesNo
If yes, Please specify:
Have you been required to take antibiotic pre-medication prior to dental treatment?
YesNo
If yes, Please specify:
For women only: are you pregnant or think you might be pregnant?
YesNo
Do you have, or have had, any of the following?
Chest Pain (Angina)
Lung Disease
Seizures or epilepsy
Eating disorder
Heart attack
Tuberculosis
Kidney disease
Fainting or dizzy spells
Stroke
Cancer
Thyroid disease
High/low blood pressure
Rheumatic Fever
Steroid therapy
Drug or alcohol dependency
Hyper/hypoglycemia
Mitral Valve Prolapse
Diabetes
Osteoporosis medications
Mental or nervous disorder
Heart problems, murmur
Stomach ulcers
Psychiatric disorder or treatment
Other communicable disease or transmissible infection
Asthma or Emphysema
High blood pressure
Circulatory problems
Please Specify
Pacemaker
Arthritis or rheumatism
Blood transfusion
Is there any additional information related to your health that has not been addressed above?
YesNo
If yes, Please specify
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in my health or medication.

Patient or Guardian Name:
Today's Date:
Patient or Guardian Signature:
You may choose to upload a photo of your insurance information (e.g. insurance card) or any other document you may think necessary