Patient Registration Form


Fields with * is required

Personal Information





Gender*:
MaleFemale






 







MineSpouse'sMom'sDad's





I was referred by:

Family/FriendsWalked InYellow PagesInternetNewspaper






Personal Responsible for Account







Title:


Complete the following if address is different from above.


 










Payment Method

Insurance/Benefits PlanCashChequeVisaMastercardAmex




Alternate Contact Person

In case of an emergency, we would like to contact someone with a different address and phone number from yours.





Health Information





Have you ever had any of the following diseases or medical problems? Please check all that apply.
If "Yes", please specify or list in box below.

Hearth Problems
Hearth Murmur
Stroke
Congenital Heart Defect
Rheumatic Fever
Pacemaker
Artificial Heart Valves
High Blood Pressure
Low Blood Pressure
Anemia
Hip/Joint Replacement
Sickle Cell Anemia
Chest Pain
Lung Problems
Difficulty Breathing
Emphysema
Bronchitis
Asthma
Tuberculosis (TB)
Liver Trouble, Hepatitis
Yellow Jaundice
Kidney Problems




Arthritis
Glaucoma
Diabetes
Stomach Ulcers / Colitis
Thyroid Problems
Epilepsy / Seizures / Fainting
AIDS (or related diseases)
Cancer
Chemotherapy / Radiation
Bleeding Problems
Headaches, severe/frequent

Have you had any other medical problem not listed above? If "yes", please specify



Are you under the care of a physician?
Are you taking any medications now?
Have you been told to take antibiotics before dental appointments
Have you been hospitalized in the last 15 years?
Have you had any previous surgery?
Have you had an elevated temperature under general anaesthesia?
For Females: Are you pregnant? If “Yes”, week #:
Have you ever had orthodontics?
Do you wear contact lenses?
Do you smoke?




PenicillinTetracyclineClindamycinMetronidazoleCodeineErythtomycinLatexAspirinDental Anesthetics


Please list or expand on any item:




INFORMATION, CONSENT & OFFICE POLICIES

I understand that the information I have given is correct to the best of my knowledge. I consent to the performing of dental procedures which have been discussed with me and agreed to be necessary or advisable.

I understand that the payments from my dental benefits may be below the current fees of General Practitioners in Ontario and that I am responsible to the dentist for any portion of the claims not covered by my dental plan. I authorize my insurance claims to be submitted electronically where applicable.

For cash patients, payment is due in full unless prior arrangements have been approved.

We reserve our staff and facilities for you. We kindly ask that you honour your appointment times. Should you need to cancel or change your appointment, we require 2 business days notice, in which case no charge will be made. This will allow us to give the time reserved for you to someone in need.

Thank you for your cooperation.

I read and agree with all the terms above