Mr. Mrs. Ms. Miss. Dr.

*First Name:

Middle Initial:

*Last Name:

*Street:

*City:

*Province:

*Postal Code:

Tel. Home:

Tel. Cell:

Tel. Work:

*E-mail:

*Date of Birth:

Family Dentist

Are you experiencing any discomfort at this time?

Yes No

Is the pain affected by?

Hot Cold Biting

Are you taking (taken) pain medication?

Yes No

General health:

Excellent Good Fair Poor

List all medications you are currently taking or provide a list to the receptionist:

Are you allergic to any of the following:

	Yes	No		Yes	No
Aspirin			Clindamycin
Codeine			Erythromycin
Ibuprofen			Latex
Local Anesthetics			Penicillin

Other medication allergies:

Indicate which of the following you presently have or have ever had:

	Yes	No		Yes	No
Aids			Blood thinners
Stroke			Lung disease
Anemia			Cancer
Tuberculosis			Nervous disorder
Angina pectoris			Diabetes Type I or II
Artificial joints (hip, knee)			Organ transplant
Congenital heart lesions			Epilepsy or seizures
Asthma			Medical implant
Heart Murmur			Glandular problems
Blood disorders			Rheumatic fever
Heart rhythm disorder			Head/Neck injuries
Cortisone/steroids			Stomach intestinal problems
Mitral valve prolapse			Hepatitis B or C
Emphysema			Artificial heart valve
Liver disease			Fainting or dizzy spells
Thyroid disease			Heart disease or attack
Malignant hyperthermia			Glaucoma
Ulcers			Heart pacemaker
Radiation treatment / chemotherapy			High / Low blood pressure
Osteporosis			Heart Surgery
Sinus trouble			Kidney disease

Other Condition(s)

Do you take Bisphosphonate (e.g. Fosamax) for Osteoporosis?

Yes No

Are you pregnant?

Yes No

Are you taking birth control pills?

Yes No

Are you nursing?

Yes No

Patient / Parent / Guardian Name:

hereby authorizes Endodontic Care to perform the service indicated, to administer local anesthetics, and to perform any added procedures which may be necessary to the welfare of the patient during the authorized services.

I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at or before completion of treatment, unless other specific arrangements are made with the receptionist.

I also authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically, I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same.

I understand that this office follows the Federal Privacy Legislation (PIPEDA) in protecting my personal information. I consent to the sharing of personal information with my referring dentist and other dental/health care providers. I consent that this office will efficiently manage my account, including billing, debit and credit card payments, credit authorization, and for collection purposes.

I understand that alternative treatments will be discussed and I will be given the opportunity to ask any questions before proceeding with treatment.