Patient Form

Salutation

First Name

Last Name

Date

Registering for a child ?

Yes

Contact Information

Home Phone

Cell Phone*

Work Phone

Address

Street Address

Province

City

Postal Code

In case of emergency, please notify:

Name

Relation

Home Phone

Cell Phone

Work Phone

Contact Options

I prefer appointment reminders by

Phone

SMS (TEXT)

Whom may we thank for referring you?

Are any other members of your family patients at our practice?

Yes

Insurance Information

Insurance applies to me

Yes, insurance applies to me

No, insurance does not apply to me

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 complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?

Yes

Not Sure/Maybe

When was your last medical checkup?

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

Yes

Not Sure/Maybe

Are you taking any prescription, non-prescription medications, or herbal supplements?

Yes

Not Sure/Maybe

Do you have any allergies?

Yes

Not Sure/Maybe

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes

Not Sure/Maybe

Do you have or have you ever had asthma?

Yes

Not Sure/Maybe

Do you have or have you ever had any heart or blood pressure problems?

Yes

Not Sure/Maybe

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

Yes

Not Sure/Maybe

Do you have a prosthetic or artificial joint?

Yes

Not Sure/Maybe

Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?

Yes

Not Sure/Maybe

Have you ever had hepatitis, jaundice, or liver disease?

Yes

Not Sure/Maybe

Do you have a bleeding problem or bleeding disorder?

Yes

Not Sure/Maybe

Have you ever been hospitalized for any illnesses or operations?

Yes

Not Sure/Maybe

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

Yes

Not Sure/Maybe

Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?

Yes

Not Sure/Maybe

Do you smoke or chew tobacco products?

Yes

Not Sure/Maybe

Are you nervous during dental treatment?

Yes

Not Sure/Maybe

For women only: Are you pregnant or breastfeeding?

Yes

Not Sure/Maybe

Dental History

Do you have any specific dental concerns? Please list:

When was your last dental appointment?

How often do you see the dentist?

Not Applicable

Every 6 months

Once a Year

Only when something is bothering me

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

Have you ever whitened (bleached) your teeth?

Yes

Not Sure/Maybe

Do you feel uncomfortable or self-conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Signature

Clear

I agree to receive emails with related information and updates.

Send

Thank you! Your message has been sent.

Unable to send your message. Please fix errors then try again.

Patient's Registration Form

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Insurance Information

Medical History

Dental History

Mon :
10:00 AM - 07:00PM

Tue - Wed :
09:00 AM - 05:00PM

Thur :
08:00 AM - 04:00PM

Fri - Sun :
Closed

Email : [email protected]

Phone :
604-985-2328

Address :
233 West 1st St,
Unit 220, North Vancouver, BC V7M 1B3