Patient Title *
Patient Name *
Date of Birth *
Current Age (Years) *
AB Health Care No. *
Street Address *
Postal Code *
Preferred Phone No. to be Contact at *: HomeWorkCell
Referring Dentist *
Emergency Contact *
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? *
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
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.)? *
Please list the allergen and the reaction had:
Have you ever had an adverse reaction (nausea, dizziness) to any medications or injections? *
If yes, please explain:
Do you have or have you ever had asthma? *
If yes, do you use an inhaler & if so what kind?
Will you bring your inhaler with you to your appointment?
Do you have an artificial or prosthetic joint/heart valve? *
Do you have any conditions or have you had any therapy that could affect your immune system? (Ie. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy) *
Have you ever had hepatitis, jaundice or liver disease? *
Do you have a bleeding problem/disorder? *
Have you ever been hospitalized for any illness or operations? *
Do you smoke or chew tobacco products? *
Are you anxious/nervous during dental treatment? *
Have you been prescribed medication in the past to help you relax during dental appointments? *
If yes, which type?
For Women: Are you pregnant or breast-feeding?
If you're pregnant, how many months?
Are there any other conditions not listed that you have had? If so, what?:
I confirm that the above information is correct, to the best of my knowledge. Further, I consent to the collection, use or disclosure of my or my dependents (“the patient”) personal information as it is required for my own and/or dependents dental care. I also consent to receiving emails regarding my treatment.
(Please fill out if you would like us to submit claims to your insurance company on your behalf)
Group Plan No.
Primary Subscriber Name
Date of Birth
Secondary Subscriber Name
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.
I understand that I am fully responsible for the prompt and full payment of my account. I also authorize the release of financial information to my dental plan benefits plan administrator and the Canadian Dental Association in order to facilitate the submission of my electronic dental claims submission by this office on my behalf.