Downtown Whitby Dentistry

Patient Intake Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

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:
Preferred Name:
Patient's D.O.B.
Sex:

Address:
City:
Province:
Postal Code:
Marital Status:

Employer:
Position:
May we contact you at your workplace?

 
May we contact you by email?

Work Number:

Cell Number:

E-mail Address

In case of an emergency please notify:

Phone Number:

Best way to contact you?
 
Best time to contact you?
 
 

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:

Referral Information

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

Dental History

Please share the following dates:

Date of last dental visit:
Date of last cleaning:
Date of last dental x-ray:
Your last oral cancer screening:
Do you smoke or use chewing tobacco?

If yes, how often?
If yes, for how long?

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 teeth 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

Do you have or have had any of the following?

YesNo YesNo
Dentures Partial dentures
Difficult extractions Braces
Periodontal (gum) treatments

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

YesNo YesNo
Make your teeth brighter Make your teeth straighter
Close spaces Replace black metal fillings with natural, tooth coloured fillings
Repair chipped teeth Replace missing teeth
Replace old crowns that don’t match Have a smile makeover
What is the name of your previous dentist?
Why did you leave your previous dentist?
What if anything, in the past kept you from having dental treatment?
What is the most important thing to you about your future smile and dental health?

Medical History

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
Radiation (head/neck) Other

Do you have any of the following allergies?

YesNo YesNo
Penicillin Latex
Aspirin Local anaesthetic
Codeine Percocet
Sulpha Nitrous oxide
Erythromycin Valium
Other
Have you ever had a joint replacement?

If yes, when?
Has your physician ever told you to take antibiotics prior to dental procedure?

If so, why?
Have you ever experienced complications following a medical or dental procedure?

If yes, please describe?
Is there anything else you think we should know regarding your medical history?

If yes, please describe?
Are you currently under a physician’s care?

If yes, what for?
Are you taking any medications?

If yes, please specify?
Family Physician’s Name:
Phone Number:

Privacy Information

Consent for Collection, Use and Disclosure of Personal Information

Office Policies

Payment

You are solely responsible for payment of all fees incurred during treatment at completion of each appointment. If you have dental insurance, please remember that your insurance is a contract between you and the insurance company.

We do not accept personal cheques and cash. We do accept MasterCard, Visa, and Debit Card payments.

Appointments

We encourage you to schedule appointments that are convenient for you to keep. If you must cancel or change an appointment we must have 2 full business days notice or a charge may be levied.

Signature