New Patient Form - SignForms™

Patient Information

Title

Patient First Name

Patient Last Name

Date of Birth (D/M/Y)

Age

Gender

Male Female Other

Phone (Home)

Phone (Cell)

Phone (Work)

Home Address

City

App/Unit

Province

Postal Code

Occupation

Employer

Health Care #

Name of Family Doctor

Phone

Address

Name of Specialist

Phone

Address

In case of EMERGENCY, We should notify:

Name

Relationship

Phone

*May we send you emails about important office notification, including appointment reminders?

Yes No

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder

Date of Birth (D/M/Y)

Policy holder Contact Phone Number

Group Policy/plan Number

I.D./Certificate Number

Insurance Company Name

Marital Status

Single Married/Common Law Other

Secondary Insurance Company Information

Name of Insurance Policy Holder

Date of Birth (D/M/Y)

Policy holder Contact Phone Number

Group Policy/plan Number

I.D./Certificate Number

Insurance Company Name

Marital Status

Single Married/Common Law Other

Medical History

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. Please fill in the entire form.

Name of previous Dentist

Phone Number

Name of Pharmacy

Location

Do you have or have you ever had any of the following:

Heart condition

Stroke/T.I.A

Infective Endocarditis

General Anesthetic complications

HIV positive/AIDS

Hepatitis A/B/C

Eating disorder

Liver disease

Cancer

Tuberculosis

Intestinal/stomach problems

Hearing impairment

Osteoperosis

Anxiety

Angina (Chest Pain)

Heart murmur

Pacemaker

Diabetes: Type l or ll

Leukemia

Hemophilia

Lupus

HPV

Asthma

Snoring/sleep apnea

Above average weight gain/loss

TMJ (jaw joint) concerns

Epilepsy/seizures

Mental health issues

Heart surgery/procedures

Mitral valve prolapse

High blood pressure

Hypolglycemia

Anemia

Excessive bleeding/bruising

Thyroid disease

Herpes/Cold sores

Respiratory conditions

Dizziness/fainting

COVID-19

Arthritis

Cognitive impairment

Drug/alcohol dependency

Heart attack

Congenital heart disease

Low blood pressure

Rheumatic fever

Blood disorders

Immunedeficiencies

Kidney disease

Physical impairment

Lung disease

Ulcers/acid reflux

Vision Impairment

Joint Replacement

Depression

Tobacco Use

Other

1. Are there any conditions or diseases not listed above that you have or have had?

Yes No Not Sure

If yes, please explain

2. Do you have any allergies or sensitivities to any:

Medications

Latex/rubber products

Other (e .g . hay fever, seasonal/environmental, foods)

3. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

Yes No Not Sure

If yes, please list them

4. Has your physician ever told you to take antibiotics prior to dental procdure?

Yes No Not Sure

If yes, please mention the reason for antibiotic

5. Have you ever experienced complications following a medical or dental procedure?

Yes No

6. Are you currently being treated for any medical condition or have you been treated within the past year?

Yes No Not Sure

If yes, please explain

7. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes No Not Sure

If yes, please explain

8. Have you ever been hospitalized for any illnesses or operations?

Yes No

If yes, please explain

9. Do you identify as a patient with a disability?

Yes No

10. Are you Pregnant?

Yes No Not Sure

If yes, what is the expected delivery date?

11. Are you breastfeeding?

Yes No

12. Do you smoke or chew tobacco products?

Yes No

If yes, please indicate how many and for how long?

13. Has there been any change in your general health in the past year?

Yes No

If yes, please explain

To the best of my knowledge, the above information is correct.

Dental History Questionnaire

1. What is the reason for your visit today? Are you currently experiencing any dental problems?

2 . Have you been seeing a dentist regularly?

Yes No

3 . Are you nervous during dental visits?

Yes No

4 . Have you had a bad experience or complications during dental treatment?

Yes No

5.1. When was your last dental visit?

5.2. What was done at that appointment?

6.1. How often do you brush your teeth?

6.2. How often do you floss?

7. Do your gums bleed when you brush or floss?

Yes No Not Sure

8 . Do you feel that you have bad breath?

Yes No Not Sure

9 . Are you happy with the appearance of your teeth?

Yes No

10 . Are you happy with your smile?

Yes No

11.1. Have you ever whitened your teeth?

Yes No

11.2. Are you interested in whitening?

Yes No

12 . Is there anything about the appearance of your teeth that you would like to change?

Yes No

If yes, please explain

13 . Are you self conscious about your teeth?

Yes No

14 . Do you have any problems with your jaw (clicking, limited movement, pain)?

Yes No Not Sure

15 . Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?

Yes No

16 . What is the most important thing to you about your future smile and dental health?

I, the undersigned, certify that I have provided an accurate and complete personal and medical dental history and financial information, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medica/dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental office at once. I authorize the dentist to perform diagnostic procedure and may be required to determine necessary treatment. I also authorize the dentist to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I also authorize the dentist to perform any and all forms of treatment, medication and therapy. I consent that X-rays and photographs to be used by Dr. Subhi Alnahas and his associates for education purpose. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility of the payment of dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services, and these fees are due and payable at the time services are rendered, unless a financial agreement.

To the best of my knowledge, the above information is correct.

Person signing this form:

Patient Parent Guardian

Legally authorized representative (Printed Name)

Dentist Name, Signature & Date

First & Last Name

Valid First & Last Name is required.

Email Address

Valid email is required.

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