NEW PATIENT FORM PATIENT INFORMATION Name*Date of Birth (MM-DD-YYYY)*Cell Phone*Prefered Name*Email address*Home PhoneAddress*Occupation*OtherPrevious Dental Procedures*What did you not like about your dentist?*Have you had local anesthetic at the dentist*YesNoWhat do you do at home to care for your teeth*Is there any area that catches floss?*Do you have any difficulty chewing*Do you snore or have sleep apnea?*Referred ByPrevious Dentist*What did you like about your previous dentist*How often did you visit your last dentist*Any Adverse Reactions*Is there any area that catches food?*Do your gums ever feel tender or bleed?*If so, why?If you could change anything at all about your smile or your teeth, what would you change?*CONFIDENTIAL MEDICAL HISTORY Are you presently under the care of a physician or a medical specialist?*YesNoPhysician's NameAre you taking medication or non prescription drugs for any medical condition?*YesNoIf Yes, please list allDo you have any allergies to medications?*YesNoIf Yes, please list allDo you have any allergies, hayfever or asthma?*YesNoIf Yes, please list allHave you ever had a major surgery or required extensive medical care?*YesNoIf Yes, please list allAre you pregnant?*YesNoHAVE YOU EVER BEEN TREATED FOR: Rheumatic fever*YesNoHeart Murmur (M.V.R)*YesNoJoint Replacement*YesNoHeart Disease*YesNoStroke*YesNoArthritis*YesNoEpilepsy*YesNoBlood or Bleeding Disorder*YesNoLung Disease*YesNoCancer*YesNoHeadaches*YesNoTuberculosis*YesNoLiver or Kidney Disease*YesNoDiabetes*YesNoHigh Blood Pressure*YesNoSteroid Treatment*YesNoHAVE YOU EVER TESTED POSITIVE FOR: Hepatitis*YesNoHIV. (AIDS)*YesNoThe above information is complete to the best of my knowledge and I have not omitted any pertinent information. Signature*SendThis field should be left blank We are a Family Friendly Practice At Molson Park Dental Office, we provide family dentistry services. Toronto and Barrie dentist, Dr. Layth works with every child to build trust and comfort through the entire dental visit process. (705) 722-4848 consultationor contact us