simpleSign - Patient Intake Form - Vitavio Family Dental Clinic

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's Name:

Preferred Name:

Patient's D.O.B.

Sex:
Male Female Other

Work Number:

Cell Number:

E-mail Address

Address:

City:

Province:

Postal Code:

Emergency contact:

Phone Number:

How did you hear about us?

Insurance Company Name:

Group Policy/Plan Number:

I.D./Certificate Number:

Division #:

Name of Insurance Policy Holder:

Date of Birth:

Insurance Company Name:

Group Policy/Plan Number:

I.D./Certificate #:

Division #:

Name of Insurance Policy Holder:

Date of Birth:

Previous Dental Office:

Last Appointment:

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 ACCURATELY AND TO THE BEST OF YOUR KNOWLEDGE.

Annual Insurance Authorization and Authorized Consent to Release Information
As a courtesy to you we direct bill most insurance companies. However, in the event that we are not able to collect for service rendered after 90 days we will forward the bill to you, and you will have to deal with your insurance company directly.

Payment for all Treatment and Services rendered are my responsibility. Please Read.

I 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 I am responsible for all costs of dental treatment not covered by my insurance carrier. I hereby authorize payment directly to Vitavio Family Dental Clinic from my group insurance benefits otherwise payable to me. If my insurance pays me directly, I will be responsible for the total balance.

Payment for all treatment and services are my responsibility if my insurance plan does not pay within 90 days or my coverage has been terminated.

When was your last dental visit?

When did you have x-rays taken? Where?

How often do you brush your teeth?

How often do you floss?

Have you been seeing a dentist regularly?
Yes No

Do any of your teeth ache?
Yes No

Have you ever been advised to take antibiotics before dental appointment?

Do your gums bleed when you brush?
Yes No

Do you have any pain when you chew?
Yes No

Do you feel you have bad breath?
Yes No

Have you ever been in a vehicle accident where you experienced trauma to your jaw?
Yes No

Have you had any implant surgery?
Yes No

If so, who performed the surgery and when?

Are you being followed by a dental specialist?
Yes No

Do you have any problems with your jaw (locking, popping, pain, sound)?
Yes No

If so, elaborate.

Is there anything about your smile that you would like to change?
Yes No

If so, what?

Are you being treated for any medical condition currently or in the past year?
Yes No

If yes, explain.

Have there been any changes in your general health in the last year?
Yes No

If yes, explain.

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Yes No

If so, please list .

Do you have any allergies?
Yes No

If so, please list .

Have you ever had an uncommon or adverse reaction to any medication or injection?
Yes No

If yes, explain.

Do you have any heart or blood pressure problems?
Yes No

If yes, explain.

Do you or have you ever had a replacement or repair of a heart valve, an infection of the heart, heart condition at birth or heart transplant?
Yes No

If yes, explain.

Have you ever had hepatitis, jaundice, or a liver disease?
Yes No

If yes, explain.

Do you have a bleeding problem or bleeding disorder?
Yes No

If yes, explain.

Have you ever been hospitalized for any illnesses or operation?
Yes No

If yes, explain.

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Yes No

If yes, elaborate.

Are there any conditions or diseases not listed above that you have or have had?
Yes No

If yes, explain.

Are there any diseases or medical problems that run in your family (e.g., diabetes, cancer, or heart disease)?
Yes No

If yes, explain.

Do you smoke?
Yes No

If yes, how much.

Are you nervous during dental treatment?
Yes No

If yes, explain.

Are you pregnant or breast feeding?
Yes No

If yes, elaborate.

I authorize and give consent to Vitavio Family Dental Clinic to perform dental services agreed between the doctor and patient and/or parent or guardian deemed to be necessary or advisable, including the use of local anesthesia and other medication as indicated. I certify the statements regarding medical condition are correct. The information on this page and the medical history is correct to the best of my knowledge.

	Yes	No		Yes	No
Alzheimer’s			Angina
Anemia			Arthritis
Blood transfusion			Cancer
Chest Pain			Cold sores
Diabetes Type 1			Diabetes Type 2
Digestive Disorders/Acid Reflux			Drug or alcohol Dependency
Emphysema			Epilepsy or Seizures
Head or Neck injury			Heart Attack
Heart Murmur			High/Low Blood Pressure
HIV			Hodgkin’s Disease
Hypo/Hyperglycemia			Kidney Disease
Lung Disease			Lupus
Migraine			Mitral Valve Prolapse
Osteoporosis Medication			Pacemaker
Parkinson’s Disease			Radiation/ Chemotherapy
Rheumatic Fever			Sexually Transmitted Infection
Shortness of Breath			Sleep Apnea
Steroid Therapy			Stomach Ulcers/issues
Stroke			Thrush
Thyroid Disorder			TMJ
Tuberculosis			Hard to Freeze
No Epinephrine

Patient Intake Form

#120, 2457 Broadmoor Blvd, Sherwood Park, AB, T8H 0Y6 780-400-6752

Patient Contact Information

Primary Insurance Information

Secondary Insurance Information

Office Policies & Terms

Dental History

Medical History

Annual Consent for Treatment

Signature