New Patient Form Print PDF



Patient Full Name:
Today's Date:
Male      Female Married     Single     Child      Other   
Patient Birth Date:
Person Responsible for account:
Name of Spouse
Names of Children
Phone (Home):
Phone (Work):
Ext
Best time to call:
Mobile
Email
Preferred appointment times: Morning    Afternoon    Evening      Any Time  
  M    T     W     T    F     S
Address:  
Street
Apartment #
City
Province
Postal Code
   
Health Information
Name of Previous Dentist:
Telephone Number
Date of Last Dental Visit:
Reason for this visit:
   
Have you ever had any of the following? Please check those that apply:
AIDS / HIV
Anemia
Angina (chest pain)
Anorexia nervosa
Artificial Heart valve
Arthritis/rheumatism
Artificial Joints (hips, knees, prosthetics)
Asthma
Autism
Blood Disease
Bronchitis
Bulimia
Cancer
Circulation problems
Congenital heart lesions
Cortisone/steroid
Diabetes
Diet pill therapy
Dizziness
Drug/alcohol dependency
Emphysema
Epilepsy (seizures)
Excessive Bleeding
Fainting
Glaucoma
Growths
Glandular disorder
Head/neck Injuries
Heart Disease/attack
Heart Murmur
Heart rhythm disorder
Mitral Valve Prolapse
Migraine Headaches
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
Hodgkin's disease
Hyper (hypo) Glycemia
Jaundice
Kidney Disease
Liver disease
Leukemia
Lung disease
Malignant hyperthermia
Mental/nervous disorders
Organ transplant/implant
Psychiatric disorder
Pacemaker
Radiation Treatment
Chemotherapy treatment
Respiratory Problems
Rheumatic/Scarlet fever
Sickle Cell disease
Sinus Problems
Stomach Problems
Stroke
Thyroid Condition
Tuberculosis
Ulcers/Tumors
Venereal Disease


FOR WOMEN ONLY:
Are you breast feeding
Yes No

Are you pregnant:
Yes No
Due Date:
Adverse effects to any of the following:
Penicillin
Sulfonamide
Aspirin
Barbiturates
Codeine
Darvon
Local Anaesthetic
None
Other
     
Allergies (hay fever, latex, etc.)
Please list your Medications:

Do you have bad breath or a bad taste in your mouth? No      Yes
Do your jaws crack, pop, or grate when you open widely? No      Yes
Have you ever had any complications following dental treatment? No      Yes
please explain:
Have been to a hospital or needed emergency care during the past two years? No      Yes
please explain:
Are you now under the care of a physician? No      Yes
please explain:
   
Name of Physician:
Phone
Do you have any health problems that need further clarification?
Do you smoke? How much per day?
   
Is there anything else you would like to add to help us make your visits more comfortable?
Referral Information
Whom may we thank for referring you to our practice? Another patient (Name)  
  Medical Walk in
  Yellow Pages
  Newsletter
  Website
  Live near by
  Road Sign
  Newspaper
  Pharmacy
  Other   
 


Special Concerns:
Are you nervous about dental treatment?
Would you like more information on teeth whitening?
Would you like more information on braces?
Are you aware of night time tooth grinding?
Are you satisfied with your teeth?     
Do you require a sports mouth guard?
Insurance Holder's Information
PRIMARY INSURANCE PLANS
Name of Insured:
Is insured a patient?
Insured's Birth Date:
ID/Cert #:
Group/Plan/Policy #:
Insurance Company Name:
Insured's Employer Name:
Patient's relationship to insured:
Self
Spouse
Child
Other    
SECONDARY INSURANCE PLANS
Name of Insured:
Is insured a patient?
Insured's Birth Date:
ID:
Group#:
Insurance Company Name:
Insured's Employer Name:
Patient's relationship to insured:
Self
Spouse
Child
Other    

Financial Polices
Your insurance benefits are between you, your employer and your insurance company. Any benefit difference (deductible, fee guide, ineligible service or co-payment) is your responsibility.

A service charge of 1½% per month (18% per annum) on the unpaid balance may be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

All estimates for approximate.

I have read the above conditions of treatment and payment and agree to their content.

Privacy act:
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. I understand that Glenashton Dental Office has a privacy act & will take the steps to protect my information. I know that your office has a Privacy Code, and I can ask to see the code at any time. I agree that Dr. Harbans Singh Bamrah/ Glenashton Dental Centre can collect, use and disclose personal information about myself as set out in the privacy act.

General Release
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my treatment or dental diagnostic procedures. I authorize release, to my insuring company plan administrator and CDA, the information contained in claims submitted electronically.

Relationship to
Patient:
Date:
Printed Name of patient, parent, guardian, or guarantor of payments
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905-842-5500


333 Glenashton Dr Unit 3,
Oakville, ON, L6H 7P6


info@glenashtondental.ca