Leave this field blank

Patient Information (CONFIDENTIAL):

Name

Email (optional)

Date (optional)

Sex (optional)

Male

Female

Birthdate

Home Phone (optional)

Work Phone (optional)

Cell Phone

Address (optional)

City (optional)

Province (optional)

Postal Code (optional)

Parent/ Guardian (if patient is a minor) (optional)

Preferred method of appointment confirmations: (optional)

Call

Text

HOW DID YOU HEAR ABOUT OUR CLINIC? (optional)

Insurance Information

Treaty Number (optional)

Please list any other insurance you may have through work or a spouse below:

#1 Insurance Company (optional)

Group/ Policy# (optional)

ID/ Certificate# (optional)

(optional)

Self

Spouse

Child

Name of Policy Holder (optional)

Policy Holder Date of Birth (optional)

#2 Insurance Company (optional)

Group/ Policy# (optional)

ID/ Certificate# (optional)

(optional)

Self

Spouse

Child

Policy Holder Date of Birth (optional)

Patient Dental History:

Name of previous Dentist and Location (optional)

Date of last dental visit (optional)

Reason for Dental Visit Today (optional)

Do you like your smile? (optional)

Yes

Do your gums bleed while brushing or flossing? (optional)

Yes

Are your teeth sensitive to sweet and sour liquids / foods (optional)

Yes

Do you feel pain in any of your teeth? (optional)

Yes

Do you have sores or lumps near your mouth? (optional)

Yes

Have you had any head, neck or jaw injuries? (optional)

Yes

Have you ever experienced any of the following problems in your jaw? (optional)

Yes

Clicking (optional)

Yes

Pain (joint, ear, side of face) (optional)

Yes

Difficulty in opening or closing (optional)

Yes

Difficulty chewing (optional)

Yes

Do you have frequent headaches? (optional)

Yes

Do you clench or grind your teeth? (optional)

Yes

Have you ever had prolonged bleeding (optional)

Yes

Have you had any orthodontic treatment? (braces) (optional)

Yes

Do you have Dentures or Partial Dentures? (optional)

Yes

If YES, Please list estimated date of placement (optional)

Yes

Have you ever had periodontal treatment? (ie. Gums) (optional)

Yes

Do you feel apprehensive or scared when you receive dental treatment? (optional)

Yes

Do you feel apprehensive or scared when you receive dental treatment? (optional)

Yes

Patient Medical History:

Physician (optional)

Date of last Exam (optional)

Phone Number of Physician (optional)

Are you currently under the care of a physician? (optional)

Yes

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? (optional)

Yes

Are you currently taking any medication(s) including non-prescription medicine? If YES, what medication(s) are you taking? (optional)

Yes

Please list all current medications below: (optional)

Are you currently taking any medication(s) including non-prescription medicine? If YES, what medication(s) are you taking? (optional)

Yes

Do you use tobacco? (optional)

Yes

Do you have a drug or alcohol addiction: Recovering or Current (optional)

Yes

Please List any and all Allergies and Allergic Reactions you have experienced (Drugs, Medicines, Anesthetic, Latex, etc): (optional)

Women Only:

A) Are you pregnant or think you may be pregnant? (optional)

Yes

Please circle any of the following medical conditions that apply to you:

High Blood Pressure

AIDS or HIV Infection

Hay Fever/ Allergies

Heart Attack (if yes please indicate when)

Stroke (if yes please indicate when)

Joint Replacement (if yes please indicate when)

Rheumatic Fever

Coronary Bypass

Thyroid Problem

Fainting/Seizures

Cardiac Pacemaker

Tuberculosis

Low Blood Pressure

Heart Murmur

Radiation Therapy

Asthma

Angina

Glaucoma

Epilepsy/ Convulsions

Frequently Tired

Liver Disease

Leukemia

Anemia

Congenital Heart Defect

Diabetes

Emphysema

Respiratory Problems

Kidney Disease

Cancer

Artificial (Prosthetic) Heart Valve

Yellow Jaundice

Arthritis

Hepatitis A, B or C

Sexually Transmitted Disease

Psychiatric Treatment

Heart Transplant

Stomach Ulcers

Chest Pains

Cirrhosis

Please note any other Conditions not previously listed:_ (optional)

I certify that I have read and understand the above information to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information; including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.

urgent care

call us

why us

book online

New Patient Form

New Patient Form

Patient Information (CONFIDENTIAL):

Insurance Information

Patient Dental History:

Patient Medical History:

Follow Us On Social Media:

Contact Information

Office Hours