New Patient Form

Welcome to Dr. Ryan - Broadway Dental Centre

In order to provide you with optimum dental care we require a thorough medical and dental history, which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.

Patient's Name:

Sex
M F

D.O.B. Month

Day

Year

Street:

City:

Province:

Postal Code:

Tel. Home:

Tel. Cell:

Patient's E-mail:

Occupation

Tel. Work:

Ext.:

Please indicate the best time to contact you for appointments:
Any Time Days Only Evenings Only Weekends

Do you have family members or friends that are patients of this office?
Yes No

If YES, name:

Referred by:

In case of Emergency, Please Notify:

Relationship

Phone #

Reason for today's visit:

Please select and complete information below
Self Spouse Other

If Other, explain

Street:

City:

Province:

Postal Code:

Occupation

Tel.:

Tel. Work:

Ext.:

Is this person currently a patient at our office?
Yes No

I authorize release to my insuring company(s) plan administrator(s) the information contained in claims submitted electronically.

I hereby assign my benefits payable from claims submitted electronically to my treating dentist and authorize payment directly to him / her.

Family Doctor:

Phone #:

Weight:

Height:

Are you presently under a doctor's care?
Yes No

Are you presently taking any drug or medication, or have you taken any in the last 6 months?
Yes No

If so, which:

Are you presently taking homeopathic products?
Yes No

If so, which:

Have you ever been hospitilized or have you ever had surgical intervention other than dental?
Yes No

Have you ever been diagnosed or treated for cancer?
Yes No

Have you ever had a heart transplant, heart infection, artificial heart valve or heart condition from birth?
Yes No

Do you smoke or chew tobacco products?
Yes No

Do you have any conditions / therapies that could affect your immune system (e.g. Leukemia, AIDS, Chemo)?
Yes No

If you selected OTHER, please specify:

Are you pregnant or think you are pregnant?
Yes No

Are you presently nursing?
Yes No

Are you presently taking oral contraceptives?
Yes No

If you selected OTHER, please specify:

Last visit:
0-6 months 6-12 months > 12 months

When did you last have dental X-rays?

How often do you brush your teeth?

How often do you floss your teeth?

Have you been seeing a dentist regularly?
Yes No

Do any of your teeth ache?
Yes No

Do your gums bleed when you brush?
Yes No

Do you have any pain when you chew?
Yes No

Do you feel that you have bad breath?
Yes No

Have you ever experienced any blows to your jaw?
Yes No

Have you ever had any implant surgery to your jaw?
Yes No

Have you ever been advised to take antibiotics before dental appointments?
Yes No

Are you being followed up by a dental specialist?
Yes No

Are you nervous during dental treatment?
Yes No

I, the undersigned, hereby declare that I have read, understood and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform my dentist of any changes to my health.

I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of the treating dentist(s).

I have been informed that my file will be kept in the office at all times and that only the dentist(s) and his / her auxiliary personnel will have access to it.

I also have been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.

I have read and understood the above policies and give consent.

	Yes	No		Yes	No
Specific Foods			Sulfa Drugs
Antibiotics (Penicillin)			Aspirin / Codeine
Iodine			Local Anesthetics
Latex (Rubber)			Metals
Sedatives			Flavours (e.g. Mint)
Other

	Yes	No		Yes	No
Blood Pressure (High / Low)			Venereal Disease
Rheumatic / Scarlet Fever			Digestive Problems
Dizzy Spells or Fainting Spells			Liver Disease (Hepatitis)
Diabetes			Epilepsy
Arthritis			Eye Problems
Nervous Disorders			Back Problems
Asthma			Stomach Ulcers
Artificial Joints or Implants			Frequent Colds or Sinusitis
Hay Fever			AIDS / HIV Positive
Kidney Disease			Earaches
Thyroid Problems			Prolonged Bleeding
Skin Disease			Anemia
Lung Disease			Frequent Headaches
Tuberculosis			Mitral Valve Prolapse
Drug / Alcohol Dependency			Leukemia
Pacemaker			Osteoporosis
Other

306 Broadway, Orangeville, ON, L9W 1L3 519-940-8333

Welcome to Dr. Ryan - Broadway Dental Centre

Patient Information

Responsible Party

Medical History (Confidential)

Dental History

Informed Consent

Patient/Parent/Guardian Signature: