Patient's Name:

Patient's E-mail:

Street:

City:

Province:

Postal Code:

Tel. Home:

Tel. Cell:

Tel. Work:

Name of Spouse:

Whom may we thank for referring you to our office?

Indicate which of the following conditions apply to you presently or in the past.

	Yes	No		Yes	No
Are you in good health?			Do you smoke?
Have you ever had a serious illness, operation, or hospitalization?			Are you now under the care of a physician for any ongoing treatment or therapy?
Are you now taking any medicine, drugs, or pills?			Do you have any allergies?
Do you have any blood disorders or do you bleed excessively?			Have you ever had injury, surgery, or x-ray therapy to face or jaws?
Do you have a tendency to faint?			Do you have frequent severe headaches?
Are you on a special diet?			Rheumatic or Scarlet Fever
Do you have a prosthetic implant? (i.e. hip?)			Do you have high blood pressure?
Do you suffer from Diabetes?			Do you bleed excessively?
Do you take blood thinners?			WOMEN ONLY - Are you pregnant?

If you answered yes to taking any medicine, drugs, or pills, please list them here.

If you answered yes to having ANY allergies, please list them here.

If you answered yes to being under the care of a physician, please explain.

What concerns you most about your dental health?

Date of last dental visit?

Date of last dental cleaning?

Date of last full mouth series of X-rays?

	Yes	No		Yes	No
Do you see a dentist on a routine basis?			Are you having pain at this time?
Have you ever had Orthodontic treatment (Braces)?			Have you ever had Oral Surgery?
Have you ever had Periodontal treatment (Gum Surgery)?			Have you ever worn a bite guard or other appliance?
Have you noticed any loosening of your teeth?			Does food tend to become caught between your teeth?
Do you suffer from pain and/or swelling of your gums?			Do your gums often bleed when you brush your teeth?
Have you ever experienced clicking of the jaw?			Have you ever experienced pain (joint, ear, side of face)?
Have you ever experienced difficulty in opening or closing?			Have you ever experienced difficulty in chewing?
Do you: Clench or grind your teeth while awake or asleep?			Do you: Bite your lips or cheeks regularly?
Do you: Hold foreign objects with your teeth (such as pencils, pipe, pins, nails, fingernails)			Do you: Mouth breathe while awake or asleep?
Do you feel nervous about having dental treatment?			Have you ever had an upsetting experience in a dental office?
Is it important to keep your teeth?			Are you dissatisfied with the appearance of your teeth?

If you could, what features of your smile would you like to change?

Is there anything else about having dental treatment that bothers you?

General Consent Statement: I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge, and have not knowingly omitted any information. I authorize the dentist to perform necessary diagnostic procedures and treatments to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive.

I have read and agree to the above release.

In an effort to ensure your appointments are as pleasant and predictable as possible, we would like to give you an overview of our office policies. Please feel free to call us with any questions you may have.

About Insurance Billing

Due to the Canadian Personal Privacy Act, we are unable to access any sufficient information from your insurance company regarding your dental plan. It is your responsibility to know the details involved in your plan such as annual maximums, frequencies, and any other limitations.

In the event that your insurance provider does not pay the expected amount for whatever reason, you are responsible to pay your account in full. All accounts will be subject to a late fee of 2% per month, 30 days after a statement of account has been issued.

Your Appointment Reminders

Please understand that it is your responsibility to keep track of your appointments. We do everything we can to remind you of them in adequate time for you to make arrangements or changes for that appointment. As a courtesy, we will call you one week prior to a booked appointment and try to make confirmation calls one day prior to your appointment. Unfortunately, that is all we are able to do in order to remind you of the upcoming appointments, after that it is up to you to remember.

Our Cancellation Policy

Should you require to cancel or change an appointment please provide us with 24 hours notice to avoid a $100 fee that our dental office may charge to you.

Our desire is for you to have a pleasant experience in our office. We strive to serve you to the best of our ability in helping you attain maximum dental health.

I have read and understood the above policies.