New Patient | Dentist in Barrie & Toronto

Patient Registration And Health History

Date

First Name

Last Name

Home #

Address

Address Line 1

Address Line 2

City

Zip Code

Work #

Cell #

Birth Date

Physician

Phone #

Emergency Contact Number

Emergency Contact Name

Dental Insurance

Ins Company

Employer

Name of Insured

DOB of Insured

Group/Plan #

Certificate #

Health History

1. Have you been a patient in the hospital in the past year?

Yes

2. If you are taking any medication may we contact your pharmacy to get an updated medication list for our records?

Yes

Pharmacy Name and Location:

3. What other medications have you taken in the past month?

4. Are you allergic or reacted adversely to any of the following medications?

Please answer all with yes or no

5. Are your aware of being allergic to any other substance?

Yes

If so, please list:

6. Select any of the following that you have had or have at present:

Please answer all with yes or no

7. Do you have frequent, heavy snoring?

Yes

8. Do you have morning headaches?

Yes

9. Have you been told you stop breathing while sleeping?

Yes

10. Are you pregnant?

11. Do you have any other medical conditions we should know about?

Dental History

Permit for Operations

This is to certify that I understand and consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures.

Patient Name

Patient Registration and Health History

Dental Insurance

Health History

Dental History

Permit for Operations

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