New Patient Form
adentaloffice.com

New Patient Form - A Dental Office

Date

Patient Name (First)

Patient Name (Middle)

Patient Name (Last)

Contact Information

Address

Address Line 1

City

Province

Postal Code

Home Phone

Work Phone

Cell Phone

Work Phone Extension

Health Card Number

Date of Birth

Family Status

Gender

What sex were you assigned at birth?

Male

Female

What is your current gender identity?

Male

Female

Other

Preferred Gender Pronoun

A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!

What pronouns do you prefer that we use when referring to you? (check all that apply)

Your Family Physician

Family Physician Name (First)

Family Physician Name (Last)

Physician's Phone Number

Emergency Contact Information

In case of emergency, We should notify:

Emergency Contact Name (First)

Emergency Contact Name (Last)

Relationship

Phone Number for Emergency Contact

Employer's Name

Occupation

Payment Information

Party responsible for payment

Self

Other

Insurance Information

Please note, patient is responsible with providing us a copy of their insurance card(s).

Primary Insurance Provider

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

Name of Insured (First)

Name of Insured (Last)

Patient's relationship to insured

Insured's Date of Birth

Age

Secondary Insurance Provider

Insurance Provider/Company Name

Group Number

Certificate Number

Name of Insured

Name of Insured (First)

Name of Insured (Last)

Is Insured a patient?

Yes

Patient's relationship to insured

Self

Spouse

Child

Other

Insured's Date of Birth

Age

Medical & Dental Information

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic(s)

Yes

Which Antibiotic(s)?

Other Allergies or Adverse Reactions you might have?

Do you take blood thinners?

Yes

If the answer is yes, specify the date and score of most recent INR

Do you take any other medications, vitamins or supplements?

Yes

List any medications and dosage (including Herbal)

Have you ever had any of the following?

Please answer all with yes or no

Heart problems, or cardiac stent within the last six month

Yes

History of infective endocarditis

Yes

Artificial heart valve, repaired heart defect (PFO)

Yes

Pacemaker or implantable defibrillator

Yes

Heart murmur, rheumatic or scarlet fever

Yes

Breathing problems (eg., asthma, stuffy nose, sinus congestion)

Yes

High or low blood pressure

Yes

Sleep problems (eg, sleep apnea, snoring, insomnia, restless sleep, bedwetting)

Yes

Kidney disease

Yes

Liver disease or jaundice

Yes

Vertigo (e.g., "the room is spinning")

Yes

Thyroid, parathyroid disease, or calcium deficiency

Yes

Hormone deficiency or imbalance (e.g., polycystic ovarian syndrome)

Yes

Stomach or duodenal ulcer

Yes

Digestive or eating disorders (e.g., gastric reflux, bulimia, anorexia, celiac disease, Crohn's disease, or any inflammatory bowel disease)

Yes

Osteoporosis/osteopenia or ever taken anti-resorptive medications (eg, bisphosphonates)

Yes

Arthritis or gout

Yes

Head or neck injuries

Yes

Autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)

Yes

Epilepsy, convulsions (seizures)

Yes

Neurologic disorders (eg., Alzheimer's disease, dementia, prion disease)

Yes

Viral infections (e.g., cold sores) bacterial infections (eg., Lyme disease)

Yes

Any lumps or swelling in the mouth

Yes

Hepatitis

Yes

Hypatitis Type

HIV/AIDS

Yes

Tumor, abnormal growth

Yes

Radiation therapy

Yes

Chemotherapy, immunosuppressive medication

Yes

Specify any of the above conditions

Surgery Details

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

Yes

If Yes, Please Explain

Have you ever had any complications following dental treatment?

Yes

If Yes, Please Explain

Are you now under the care of a physician, regarding an ongoing medical issue?

Yes

If Yes, Please Explain

Have you or anyone related to you ever had problems with local anaesthetic?

Yes

If Yes, Please Explain

Do you have any health problems that need further clarification?

Yes

If Yes, Please Explain

Do you smoke?

Yes

Used to

How many cigarettes a day?

When did you quit?

Do you use any recreational drugs?

Yes

Please list what kind

Do you have a prosthetic or artificial joint?

Yes

Where?

Radiation Treatment?

Yes

Where on body and when?

When was your last dental visit?

When was your last have dental x-rays?

How often do you brush your teeth?

How often do you floss your teeth?

Select all that apply

Some or all of your teeth ache

Your gums bleed when you brush

You have pain when you chew

You feel you have bad breath

Please list anything else not mentioned above regarding your past dental history.

Whom may we thank for referring you to our practice ?

Google

Facebook

Instagram

Yellow Pages

Work

Newspaper

Walk-by / Business sign

Current patient of ours. Provide us with a name, so we can thank them.

Other

Please specify

Name of referrer

Consent for Services & Office Agreement

I understand that my family’s appointments are valuable, and that 2 Business days must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.
I will be required to pay for my family treatment at each visit. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).
I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.
I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.
My dental insurance plan is a contract between myself and the organization providing me with the coverage.
It is my responsibility to ensure that the treatment I request is covered. However, adentaloffice.com will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. adentaloffice.com has NO knowledge of what is covered by my insurance plan. If I have a booklet, adentaloffice.com will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. adentaloffice.com will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.
adentaloffice.com also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.
adentaloffice.com will always make every attempt to see emergency cases promptly.
adentaloffice.com will accept Visa, MasterCard, debit and cash.
adentaloffice.com will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.

Consent and Awareness of Use for Email and Text

It is my request to use email/text.
Email/text is not a secure system for sending/receiving information.
Email/text conversations will be documented in my clinical record.
No Email/text either sent by myself or a staff member will be forwarded to anyone else without consent of the other party.
Any decision by either myself or a staff member to stop the use of email/texts will be respected.

Consent for Collection, Use and Disclosure of Personal Information

I agree that adentaloffice.com has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.

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

Signature of patient, parent or guardian

Date

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New Patient Form
adentaloffice.com

Contact Information

Gender

Preferred Gender Pronoun

Your Family Physician

Emergency Contact Information

Payment Information

Insurance Information

Primary Insurance Provider

Name of Insured

Secondary Insurance Provider

Name of Insured

Medical & Dental Information

Have you ever had any of the following?

Consent for Services & Office Agreement

Consent and Awareness of Use for Email and Text

Consent for Collection, Use and Disclosure of Personal Information

Menu

Services

Resources

Information

New Patient Formadentaloffice.com

Contact Information

Gender

Preferred Gender Pronoun

Your Family Physician

Emergency Contact Information

Payment Information

Insurance Information

Primary Insurance Provider

Name of Insured

Secondary Insurance Provider

Name of Insured

Medical & Dental Information

Have you ever had any of the following?

Consent for Services & Office Agreement

Consent and Awareness of Use for Email and Text

Consent for Collection, Use and Disclosure of Personal Information

New Patient Form
adentaloffice.com