New Patient Medical Form

Patient Information

Patient Title *

Mr.Mrs.Ms.Dr.

Patient Name *

Date of Birth *

Current Age (Years) *

AB Health Care No. *

Street Address *

City *

Province *

Postal Code *

Phone (Home)

Phone (Work)

Phone (Cell)

Preferred Phone No. to be Contact at *:

Referring Dentist *

Phone

Emergency Contact *

Relationship *

Phone *

Medical Information

The following information is required so that we may provide you with the best possible care. All information is strictly private and is protected by doctor-patient confidentiality. The doctor will review all of the questions. Please fill out the entire form. If you need further clarification of any of the questions, please ask a team member or the doctor.

Are you currently being treated for any medical condition now or within the past year? *
YesNoNot Sure

If yes, please explain the condition:

Describe any current medical treatment, upcoming surgery or upcoming treatment that may affect your dental treatment:

Do you have or have you ever had any of the following conditions?

Heart Disease/Murmur/AnginaPacemakerSwollen AnklesHigh Blood PressureLow Blood PressureHigh CholesterolKidney Disease/Bladder IssuesStomach Issues/UlcerReflux Issues/Ulcerative ColitisBlood Problems/AnemiaLiver Disease/HepatitisBone Disorder/OsteoporosisEating DisorderCancerRadiation or ChemotherapySteroid TherapyLung Condition/Asthma/CoughHeadaches/MigrainesArthritis/Muscle WeaknessStroke/Transient Ischemic AttackDiabetesThyroid ConditionAdrenal Gland IssuesSinus ProblemsSeizures/EpilepsyNeurological ConditionPsychiatric CareDepressionAlcohol DependencyAnxietyHearing Loss/Ear ConditionMalignant HyperthermiaTuberculosis

Please explain:

List any medications, supplements or vitamins taken within the last 2 years, and purpose they were taken for:

Do you have any allergies that result in rash, hives or swelling (Ie. to medications, latex products, etc.)? *
YesNo

Please list the allergen and the reaction had:

Have you ever had an adverse reaction (nausea, dizziness) to any medications or injections? *
YesNo

If yes, please explain:

Do you have or have you ever had asthma? *
YesNo

If yes, do you use an inhaler & if so what kind?

Will you bring your inhaler with you to your appointment?
YesNo

Do you have an artificial or prosthetic joint/heart valve? *
YesNo

Do you have any conditions or have you had any therapy that could affect your immune system? (Ie. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy) *
YesNo

If yes, please explain:

Have you ever had hepatitis, jaundice or liver disease? *
YesNo

Do you have a bleeding problem/disorder? *
YesNo

Have you ever been hospitalized for any illness or operations? *
YesNo

If yes, please explain:

Do you smoke or chew tobacco products? *
YesNo

Are you anxious/nervous during dental treatment? *
YesNo

Have you been prescribed medication in the past to help you relax during dental appointments? *
YesNo

If yes, which type?

For Women: Are you pregnant or breast-feeding?
YesNo

If you're pregnant, how many months?

Are there any other conditions not listed that you have had? If so, what?:


Date:


Dental Insurance

(Please fill out if you would like us to submit claims to your insurance company on your behalf)

Primary Insurer

Group Plan No.

ID #

Primary Subscriber Name

Date of Birth

Secondary Insurer

Group Plan No.

ID #

Secondary Subscriber Name

Date of Birth

Please note that the complete cost of the dental visit will be due on the date of service by Visa, MasterCard or Debit. We do not accept personal cheques or cash. We can assist you by sending your insurance forms to your insurance company on your behalf. Your insurance company will reimburse you directly for the coverage you have with them.

Date: