Dentistry Dunnville

Patient Intake Form

105 Lock Street E, Dunnville, ON N1A 1J6      905-774-7608

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 Full Name:
Preferred Name:
Patient's D.O.B.
Sex:
Address:
City:
Province:
Postal Code:
Home Number:

Work Number:

Cell Number:

E-mail Address

Employer / School:
Position / Occupation:
Best way to contact you?
 
Person to contact in case of an emergency (relationship):

Phone Number:

Family Doctor:
Phone Number:
Pharmacy Name:
Phone Number:

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number:

Secondary Insurance Company Information

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number:
Method of Payment

Referral Information

How did you hear about us? (Check all that apply)
 

Medical History

Have you had a medical check-up in the last year?
If yes, when?
Have you ever been hospitalized or had major operations?
If so, please explain
Are you currently under a physician’s care?
If yes, what for?
Have you ever had an unusual reaction to any medications or injections?
If yes, please describe:
Are you taking any medications, non-prescription drugs, recreational drugs, or herbal supplements?
If yes, please specify:
Do you drink, smoke, vape or chew tobacco products?
If yes, explain:
Do you require pre-medication for dental treatment?
Details:
Have you ever had any organ implant or medical implants? (i.e. valves, stents, joints)
If yes, please specify:
Do you experience shortness of breath or chest pains when taking a walk or climbing stairs?
If yes, please specify:
Have you had any injury, surgery or x-ray therapy to your face or jaws?
If yes, please specify:
For Women Only:
Are you pregnant or suspect you might be?
If so, what month are you in?
Are you taking birth control pills?
Are you nursing?
Do you have or have ever had any of the following:
YesNo YesNo
AIDS Drug addiction
Allergies, seasonal Emphysema
Anemia Excessive bleeding
Arthritis Fainting
Artificial heart valve Glaucoma
Artificial joints Heart conditions
Asthma Heart lesions, congenital
Blood disease Heart murmur
Bruise easily Heart surgery
Cancer Hepatitis A
Chemotherapy Hepatitis B
Diabetes Hepatitis C
Dizziness High blood pressure
HIV positive Respiratory problems
HPV Rheumatic fever
Jaundice Rheumatism
Jaw joint pain Scarlet fever
Kidney disease Seizures
Liver disease Sleep apnea
Low blood pressure Stomach problems
Mitral valve prolapse Stroke
Nervousness/Depression Thyroid disease
Pacemaker Tuberculosis
Phen fen (1 month+) Ulcers
Pregnant currently Venereal diseases
Do you or have you ever had any other illness not listed above?
If yes, please explain:

Do you have any of the following allergies?

YesNo YesNo
Penicillin Latex
Aspirin Local anaesthetic
Codeine Percocet
Sulpha Nitrous oxide
Erythromycin Valium
Other

Dental History

What is your main priority in seeking dental treatment?
How frequently do you see your dentist?
Date of last dental visit:
Date of last hygiene visit:
Date of last dental x-ray:
Your last oral cancer screening:
How often do you brush your teeth?
How often do you floss?
Do your gums bleed easily?

Please check any of the following problems that may apply to you:

YesNo YesNo
Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing
Bleeding gums or fillings Broken teeth or fillings
Loose, tipped or shifting teeth Headaches, earaches or neck pain
Grinding or clenching teeth Jaw joint pain (clicking/cracking)
Bad breath or bad tasted in your mouth Sore spots/growths
Have you had any negative experiences with dentistry?
Have you ever had trouble getting numb/frozen?

Do you have or have had any of the following?

YesNo YesNo
Orthodontics Oral Surgery
Gum treatment Root Canal
Implants Dentures
Night Guard Braces

If you could change your smile, you would...

YesNo YesNo
Whiter teeth Straighter teeth
Close spaces Replace black metal fillings with natural, tooth coloured fillings
Repair chipped teeth Replace missing teeth
Replace old crowns that don’t match Smile makeover
Other dental concerns:

Privacy & Release Information

Release of Information: I authorize Dentistry Dunnville to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history friom my physician, another dental office, insurance company.
Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 2 days notice, otherwise it may be necessary to charge for the time lost.
Patient Release: I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

Signature