New Patient Form Print PDF

Patient Full Name:
Today's Date:
Gender:	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?	No Yes
Would you like more information on teeth whitening?	No Yes
Would you like more information on braces?	No Yes
Are you aware of night time tooth grinding?	No Yes
Are you satisfied with your teeth?	No Yes
Do you require a sports mouth guard?	No Yes

Insurance Holder's Information

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