New Patient Form - Willowdale Dental Associates

The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Patient Contact Information

Patient's Name:

E-mail:

Patient's D.O.B.

Sex:

Male Female

Home Phone #:

Cell #:

Address (Inc. Apt # if applicable):

City:

Province:

Postal Code:

Person responsible for account: Self / Other

Do you have a dental plan?

Yes No

Insurance Company:

Group Policy/Plan Number:

Certificate / ID #:

Employer:

Occupation:

What is the name of your previous dentist?

Family Physician:

Phone Number:

In case of an emergency please notify:

Relationship:

Telephone:

Referred by

Another Patient/Family or Friend? (name)

Internet - Website/search engine source:

Flyer — flyer description:

Yellow Pages

Gold Book

Other — please specify:

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. Please fill in the entire form.

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

Yes No

If yes, explain

Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind?

Yes No

If yes, please specify

Do you have any allergies? (e.g. penicillin, latex/rubber product)

Yes No

If yes, please specify

Do you have a heart problem of any kind?

Yes No

If yes, please explain

Have you ever been hospitalized for any illness or operations?

Yes No

If yes, please explain

Do you smoke cigarettes?

Yes No

If yes, how many?

Do you drink alcohol?

Yes No

If yes, how much and how often?

Do you do recreational drugs?

Yes No

If yes, please explain?

Do you have or have you ever had any of the following? Please check those that apply.

Have you ever had any illness not included above?

Yes No

If yes, please specify

Dental History

Date of your last dental visit:

Reason for today's visit:

Examination and Cleaning?

Emergency or Specific Problem?

Other

Office Policy (Please Read)

We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to paid for at each visit as they are performed.

Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.

I authorize Willowdale Dental Associates - Yonge & Sheppard to perform all dental or diagnostic procedures agreed to be necessary or advisable, including x-rays, photographs, and the use of local anaesthetic or other medications as indicated. I understand that if I miss an appointment or provide less than 48 hours notice to cancel or reschedule an appointment, I may be charged a cancellation fee. I assume full responsibility for fees associated with my dental treatment and those of my dependents. I have read and fully understand the above conditions of treatment and I accept my responsibility as a patient at this office.

	Yes	No		Yes	No
Are you in good health?			Do you bleed or bruise easily?
Have you ever had a heart murmur, mitral valve prolapse or rheumatic Fever			Have you ever been advised by your doctor to take antibiotics before dental treatment?
Have you ever been exposed to Hepatitis or Jaundice?			Women only: Are you pregnant or breast-feeding?

	Yes	No		Yes	No
HIV			Hepatitis A
Hepatitis B			Hepatitis C
AIDS			Dizziness
Anemia			Epilepsy
Arthritis/Rheumatism			Excessive bleeding
Asthma			Fainting
Blood Disease			Hay Fever
Cancer			Head Injuries
Diabetes			High/Low Blood Pressure
Hip Replacement Surgery			Stomach Ulcer
Knee Replacement			Stroke
Kidney Disease			Thyroid Problem
Liver Disease			Tuberculosis
Lung Disease			Venereal Disease
Mental Disorder			Prosthetic Heart Valve

	Yes	No		Yes	No
Have you ever had a dental examination with a full series of x-rays of your teeth and jaws?			Tooth pain or discomfort while chewing
Have you ever had any problems/reactions to local anaesthetic?			Are your teeth sensitive to Cold?
Are your teeth sensitive to Heat?			Are your teeth sensitive to Sweets?
Are your teeth sensitive to Other Things?			Do your gums bleed when: Brushing?
Do your gums bleed when: Flossing?			Do your gums bleed when: Spontaneously?
Does food lodge between your teeth?			Does your jaw crack, pop or grate when opened widely?
Do you grind or clench your teeth?

Patient Registration, Health History & Office Policies

25 Sheppard Ave. W., #125, North York, ON, M2N 6S6 416-226-2535

Patient Contact Information

Medical History

Dental History

Office Policy (Please Read)

Signature