New Patient Intake Form

Welcome to Dental Specialists of Windsor

Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential and will remain with this office. Our receptionist is available to assist you with the completion of this form.

*Patient's Name:

*Patient's E-mail:

*Patient's D.O.B.

*Street:

*City:

*Province:

*Postal Code:

Tel. Home:

Tel. Cell:

Tel. Work:

Occupation

Place of Business:

May we text you to confirm appointments?
Yes No

May we call you at work?
Yes No

May we email you to confirm appointments?
Yes No

In case of Emergency, Please Notify:

Relationship

Phone #

Family Physician:

Physician's Phone #:

Family Dentist:

Dentist's Phone #:

Are you currently in good health?
Yes No

If NO, please explain

Have you been under the care of a physician during the last two years?
Yes No

If YES, please explain

Do you have any other sensitivities/allergies not listed above?

Do you smoke cigarettes, pipe, cigars, marijuana, hookah?
Yes No

if yes, how many / much per day?

List all forms of tobacco and marijuana use.

Are you alcohol and/or drug dependant?
Yes No

If yes, have you received any treatment?
Yes No

Please list any pills currently taken: (Prescription & non-prescription drugs, vitamins, herbal meds, Aspirin, etc.)

Name

Reason

Name

Reason

Pharmacy name and location

Pharmacy phone number

List any other illness not included above:

When was your last dental visit?

Date of last dental cleaning?

Are you currently in pain?
Yes No

Do your gums bleed when BRUSHING:
Yes No

Do your gums bleed when FLOSSING:
Yes No

Do your gums bleed SPONTANEOUSLY:
Yes No

Do your gums feel swollen or tender?
Yes No

Are you aware of any loose teeth?
Yes No

Are your teeth sensentive to COLD:
Yes No

Are your teeth sensentive to HOT:
Yes No

Are your teeth sensentive to SWEETS:
Yes No

How often do you brush your teeth?

Have you had any of the following dental treatments in the past?

Orthodontic treatment (braces)
Yes No

Oral Surgery (extractions, jaw surgery)
Yes No

Periodontal treatment (gum treatment)
Yes No

Are you anxious about receiving dental treatment?
Yes No

Do you require Antibiotic coverage prior to dental cleanings?
Yes No

If yes, which antibiotic do you take?

Welcome to our office. It is our goal to provide you with the highest possible standards of dental care. Please remember that once you have made an appointment, this time is reserved for you. If cancellation is necessary, we would ask for at least 48 hours notice to prevent delays in treatment. Failure to give adequate notice may result in a cancellation fee.

This office bases its fees on the current Ontario Dental Association fee guide. Office policy is that services are to be paid for at each visit as they are performed. If your dental plan does not cover the full cost of your treatment, you will be responsible for any difference between the amount paid by your plan and the amount charged for your treatment.

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted if necessary. I understand that the responsibility for payment for the dental services provided for myself, or my dependents, is mine, and I will assume responsibility for fees associated with these services.

I have read and agree to the above release.

	Yes	No		Yes	No
Penicillin			Aspirin/Anti-inflammatory pills
Erythromycin			Latex
Tetracycline			Local Anaesthetic (dental freezing)

	Yes	No		Yes	No
Anemia			Heart Attack
Lung Disease			Artificial Heart Valve
Heart Murmur			Malignant Hyperthermia
Artificial Joints (hip, knee, etc)			Heart Pacemaker
Mitral Valve Prolapse			Heart Arrhythmia
Organ Transplant			Blood Disorder
Heart Surgery			Osteoporosis
Bronchitis			Hepatitis (A, B, C, D)
Radiation Therapy			Cancer
Chemotherapy			Circulatory Problems
High Blood Pressure			Sinus Problems
Cholesterol (High)			Low Blood Pressure
Stomach/Intestinal Problems			Diabetes
HIV/AIDS			Stroke
Emphysema			Hypoglycemia
Thyroid Problems			Epilepsy
Kidney Disease			Tuberculosis
Heart Disease			Liver Disease

5745 Wyandotte St. E., Suite 100, Windsor, ON, N8S 1M6 519-974-0230

Welcome to Dental Specialists of Windsor

Personal Information

Medical History

Medical History

Dental History

Office Policy

General Release

Patient/Parent/Guardian Signature: