New Patient Form

Salutation*

Ms.
Mrs.
Mr.
Dr.

Patient Name*

First Last

Phone Number:*

Birthdate*

E-mail Address*

Home Address*

Street Address Address Line 2 City Province Postal Code

Sex*

Female
Male

In case of emergency, please contact:*

Emergency Contact Phone*

Who can we thank for referring you?

Personal Responsible For Account

Person responsible for this account*

Name*

First Last

Address*

Street Address Address Line 2 City Province Postal Code

Phone

Cell*

Birth Date*

Sex*

Female
Male

Employment Information

Employer*

Work Phone*

Work Phone Ext.

Occupation*

Union Local

Primary Insurance

Primary Insurance – Name of insured*

Insurance company*

Policy #*

Cert #*

Div #*

Relation*

Self
Spouse

Is there a secondary insurance?*

Yes
No

Secondary Insurance

Secondary Insurance – Name of insured*

Insurance company*

Policy #*

Cert #*

Div #*

Relation*

Self
Spouse

Medical and Dental History

Family physician*

Physician Phone*

Previous Dentist*

Previous Dentist Phone*

When was your last dental x-rays?*

When was your last dental cleaning?*

Any previous problems with dental treatment? Please explain*

Yes
No

Please explain previous dental treatment problems*

Are you satisfied with the appearance of your teeth?*

Yes
No

Please explain your dissatisfaction with your teeth appearance*

Have you ever had gum surgery?*

Yes
No

Have you ever had orthodontics (braces)?*

Yes
No

Have you ever had endodontics (root canal)?*

Yes
No

Which oral surgery have you had (check all that apply)?*

Select All
Wisdom teeth removal
Dental implants
Crowns
Bridges
Dentures

Reasons For Visit

Please check all dental concerns that apply to you.*

Other concerns or reasons for visit

Health History

Are you presently in good health?*

Yes
No

Do you use any tobacco products or nicotine substitutes?*

Yes
No

Type/Frequency*

Past surgeries or hospitalizations:*

Yes
No

Please describe what surgeries and hospitalizations you've had*

Are you taking any medications (prescription or herbal?)? Type:*

Yes
No

Prescription or Herbal? Type?*

Do you have any allergies?*

Yes
No

Please list your allergies.*

General

Do you presently have or have you ever had any of the following conditions (check all that apply)?*

What kind of artificial joints are they?*

What type of cancer?*

Other condition - please explain*

Your Smile Analysis

Do you like the appearance of your teeth?*

Yes
No

Are your teeth all in alignment(straight)*

Yes
No

Do you have spaces?*

Yes
No

Do you like the colour of your teeth?*

Yes
No

Do you wish your teeth were whiter?*

Yes
No

Are your teeth protruding?*

Yes
No

Are there old crowns, bridges,or fillings you don't like looking at?*

Yes
No

Are your teeth chipped OR wearing on the biting surfaces?*

Yes
No

Are your teeth hidden?*

Yes
No

What would you like your smile to look like?*

Acknowledgement

Cancellation Policy*

I agree to the cancellation policy.

Please note: we require 2 business days notice upon cancellation of appointments. A fee of $50 for hygiene or $ 75 for dentist for no show / missed appointments will be charged to your account.

Consent and Privacy*

I agree to the Consent and Privacy Policy.

Patient Release: I certify that I have provided an accurate and complete medical and dental history for myself (or my dependant) and have not omitted any information. I have had the opportunity to ask questions and have received answers regarding any concerns I have regarding my dental treatment. I authorize the dentist to consult with my physician (or specialist) regarding any compromising medical condition in my (or my dependants) medical/dental history. I have also read and understand the Privacy Act given to me to review.

Signature*

Relationship to applicant*

Self - patient
Parent
Guardian

Date of Application*

For Office Use Only

Reviewed by:

Dr. Rosanna Porretta

BOLTON FAMILY DENTAL CENTRE (289) 206-0095