New Patient Information New Patient Registration 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. First Name*Last Name*Date Of Birth dd/mm/yyyy*Phone*Email* Address*City*Province*Postal Code*DENTAL HISTORYPlease let us know the reason for this appointment?New Patient ExamEmergency ExamConsultOtherPlease explainHEALTH HISTORYPlease check YES or NO to each question. If unsure of a question, please consult the dentist.Are you being treated for any medical condition at present or within the past year?YesNoMaybe/Not SurePlease ExplainWhen was your last medical check up?Has there been any changes in your general health in the past year?YesNoPlease ExplainList and PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken including birth control pills: Do you have any allergies ?YesNoNot sureHave you ever had a peculiar or adverse reaction to any medicines or injections?YesNoNot SurePlease ExplainDo you have, or have you ever had, any heart or blood pressure problems (heart or stroke)?YesNoDo you have a heart murmur, valve dysfunction (mitral valve prolapse or artificial heart valve) or have you ever had Rheumatic Fever?YesNoDo you have any prosthetic or artificial joints (e.g. hip, knee)?YesNoDo you bleed excessively from a cut or injury, bruise easily or have any blood disorders?YesNoHave you ever been hospitilized for any illness or operations?YesNoPlease ExplainIndicate which of the following you presently have, or ever had: (Please check all that apply) Asthma Bronchitis Emphysema Lung Disease Hepatitis B or C Jaundice Liver Disease Tuberculosis Diabetes Kidney Disease Thyroid Disease Glandular Disorders Organ Transplant / Medical Implant Stomac or Intestinal Problems Ulcers Epilepsy or Seizures HIV+ Nervous Disorders Do you currently have, or ever had in the past, any disease, condition or problem not listed above?YesNoPlease ExplainAre there any diseases or medical problems that run in your family?YesNoPlease ExplainDo you smoke?YesNoWOMEN ONLY: Are you pregnant or breast feeding?YesNoNot SureIf pregnant, what is the expected delivery date?Notes or Comments:General ReleaseI, 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. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.I understand that 48 hours notice is required for changing or cancellation of my appointments, otherwise there is $50 charge per hour that may be apply.PhoneThis field is for validation purposes and should be left unchanged.