simpleSign - Patient Intake Form - Downtown Whitby Dentistry

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:

Male Female

Address:

City:

Province:

Postal Code:

Marital Status:

Single Married/Common Law Other

Employer:

Position:

May we contact you at your workplace?

Yes No

May we contact you by email?

Yes No

Work Number:

Cell Number:

E-mail Address

In case of an emergency please notify:

Phone Number:

Best way to contact you?

Home

Work

Cell

E-mail

Best time to contact you?

Morning

Afternoon

Evening

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

Insurance Policy Holder:

Self Parent/Guardian Other

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:

Self Parent/Guardian Other

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)

Internet - Website/search engine source:

Flyer — flyer description:

Newspaper — newspaper name(s):

Word of Mouth — name of person:

Walked By

Other — please specify:

Dental History

Please share the following dates:

Date of last dental visit:

Date of last hygiene visit:

Date of last dental x-ray:

Your last oral cancer screening:

Do you smoke or use chewing tobacco?

Yes No

If yes, how often?

If yes, for how long?

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

Do you have or have had any of the following?

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

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

Do you have any of the following allergies?

Have you ever had a joint replacement?

Yes No

If yes, when?

Has your physician ever told you to take antibiotics prior to dental procedure?

Yes No

If so, why?

Have you ever experienced complications following a medical or dental procedure?

Yes No

If yes, please describe?

Is there anything else you think we should know regarding your medical history?

Yes No

If yes, please describe?

Are you currently under a physician’s care?

Yes No

If yes, what for?

Are you taking any medications?

Yes No

If yes, please specify?

Family Physician’s Name:

Phone Number:

Privacy Information

I certify that I have read, understood and accurately completed the personal, medical, and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. If required, I consent to my physician being contacted regarding and specific medical question. I authorize the dentist and his/her auxiliary staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.

Consent for Collection, Use and Disclosure of Personal Information

I agree that Downtown Whitby Dentistry has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004.

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.

	Yes	No		Yes	No
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

	Yes	No		Yes	No
Dentures			Partial dentures
Difficult extractions			Braces
Periodontal (gum) treatments

	Yes	No		Yes	No
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

	Yes	No		Yes	No
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

	Yes	No		Yes	No
Penicillin			Latex
Aspirin			Local anaesthetic
Codeine			Percocet
Sulpha			Nitrous oxide
Erythromycin			Valium
Other

Patient Intake Form

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

Patient Contact Information

Insurance Information

Primary Insurance Company Information

Secondary Insurance Company Information

Referral Information

Dental History

Medical History

Privacy Information

Consent for Collection, Use and Disclosure of Personal Information

Office Policies

Payment

Appointments

Signature