Name(Required) First Last DATE OF BIRTH:(Required) MM slash DD slash YYYY MARITAL STATUS:(Required) Married Single Divorced Widow/Widower HOME PHONE:(Required)RESIDENCE ADDRESS:(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code CELL PHONE:(Required)EMPLOYED BY: POSITION: E-MAIL ADDRESS: BUSINESS PHONE:REFERRED BY: FAMILY DOCTOR:(Required) PHYSICIAN'S PHONE:(Required)NAME OF SPOUSE OR PARENT (GUARDIAN) DATE OF BIRTH MM slash DD slash YYYY EMPLOYER: METHOD OF PAYMENT: NAME OF DENTAL INSURANCE: PHARMACY NAME & PHONE NUMBER:POLICY HOLDER'S NAME: GROUP NO./ POLICY NO. : ID/CERTIFICATE NO.: Have You Ever Had Any of the Following?have you ever? Heart Problems Angina or Chest Pains Shortness of Breath High Blood Pressure Heart Murmur & Mitral Valve Prolapse Lung Disease Artificial Joint / Hip/ Knee Replacement Tuberculosis Hay Fever or Allergies Sinusitis Reumatic Fever have you ever? Anemia Asthma Kidney / Liver Problems Hepatitis Thyroid Problems Bleeding Problems Drug Reaction Epilepsy Diabetes Fainting Spells Immuno Deficiency HAVE YOU EVER TAKEN, OR TAKING NOW, ANY OF THE FOLLOWING TYPES OF PILLS AND MEDICATION?have you ever? Cortisone or Steroids Pain Pills Tranquilizers Kindey Pills Water PIlls have you ever? Blood Pressure Pills Heart Pills Blood Thinners Anti Cogulant Other Please write in the names of the pills you are taking as written on the drug bottles?(Required) Are there any pills or medicines you must not take or are allergic to?(Required) Are you pregnant and if so, which month?(Required) Is there a history of family disease? e.g. diabetes(Required) Any recent surgery(s), medical condition or illness not listed above?(Required) Approximate date of last dental check-up?(Required) MM slash DD slash YYYY Have you ever had any one fo the following?Have you ever had any one fo the following?(Required) Fillings Regular Cleanings Recent Dental X-rays Nitrous Oxide (laughing gas) Periodontics (gum treatment) caps or crowns Have you ever had any one fo the following?(Required) Extractions Root Canal Treatment Full or Partial Dentures Orthodontics (braces) An injury to your mouth or jaws Implants Do you use cannabis?(Required) Yes, regularly Only sometimes No Do you use a CPAP machine?(Required) Yes, regularly Only sometimes No Have you ever had a local anesthetic?(Required) Yes No If yes, any problems? Have you ever had an ‘unfavourable’ dental experience?(Required) Yes No If yes, any problems? Would you be interested in having nitrous oxide (laughing gas) during appointments?(Required) Yes No Do you get ‘cold sores’ or mouth ulcers?(Required) Yes No If yes, how often? Would you like to improve the general cosmetic appearance of your teeth?(Required) Yes No If yes, what would you like to change? Do you presently have or think may have the following?Do you presently have or think you may have the following:(Required) Loose Teeth Cavities Gum Disease Sensitive Teeth Bleeding Gums Do you presently have or think you may have the following:(Required) A bad taste in your mouth A clicking or sore jaw Earaches or headaches Unslightly or broken fillings Dead or abcessed teeth In your own words, describe your present dental problems or needs: OFFICE PHILOSOPHY AND POLICY: (please read) • In an effort to determine a treatment plan that is best for your overall dental health, we must make careful diagnosis. This involves a thorough examination, often utilizing the minimum number of x-rays necessary for accuracy. • We pledge to provide high quality dentistry in the most comfortable manner possible, with the best equipment, materials and up-to-date technologies. • The long-term success of our efforts will depend on the patient’s willingness to maintain healthy teeth and prevent any future dental problems. • Your appointment time will be reserved especially for you. If you are unable to keep your appointment, we require 48 hours’ notice. • Our office policy is that services are paid for each visit as they are performed. In certain circumstances, financial arrangements for payment may be made by consulting the receptionist. • Regarding Insurance: all patients with dental insurance are responsible for payment of their own accounts. We are pleased that you have insurance to reimburse or minimize your personal expenditure and we will gladly complete any claim forms to assist you in collecting your dental benefits. Please make certain you understand any limitations in your contract. We will gladly submit 'estimate' forms, if necessary. • All urgent dental problems will be attended the same day, whenever possible. You may call our office or answering service at any time. • A healthy dentistConsent for Treatment(Required) This is to certify that I consent to the performing of the dental procedures agreed to be necessary and I will assume responsibility for fees associated with those procedures.Signature(Required)Date(Required) MM slash DD slash YYYY We are pleased to welcome you to our practice and hope to provide you, your friends and relatives with the highest quality of dental care. Δ
(289) 797-2930 | Yes, we take your insurance. Call now for free, friendly advice 
(289) 797-2930 | Yes, we take your insurance. Call now for free, friendly advice