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New Patient Form
Step
1
of
6
- Personal Information
16%
Name
*
First Name
Last Name
Date of Birth
*
MM slash DD slash YYYY
Email
*
Home Phone
*
Cell Phone
*
Address
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Gender
*
Male
Female
Other
Emergency Contact
*
Emergency Contact Number
*
How did you hear about us?
*
Employer
*
Occupation
*
Do you have Dental Insurance?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
MM slash DD slash YYYY
Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
Do you have a second Insurance Provider?
*
Yes
No
Name of Dental Insurance Subscriber
*
First Name
Last Name
Date of Birth of Subscriber
*
MM slash DD slash YYYY
Name of Insurance Provider
*
Group/Plan Number
*
Certificate/ID Number
*
What's your main concern right now?
*
When was your last dental visit?
*
Previous Dental Office
*
Do your Gums feel tender/swollen?
*
Yes
No
Do your Gums bleed?
*
Yes
No
Do you have bad breath or a bad taste in your mouth?
*
Yes
No
Have you had excessive bleeding during past dental visits?
*
Yes
No
Do you grind/clench your tooth or notice any popping/clicking noises?
*
Yes
No
Do you wear a night guard?
*
Yes
No
Do you suffer from frequent migraines?
*
Yes
No
Is snoring a problem for you?
*
Yes
No
Are you happy with the way your smile looks?
*
Yes
No
Do you have any serious Medical Conditions we should know about?
*
Yes
No
Please explain.
Known Medical Conditions
No Known Medical Issues
Alcohol/ Drug Abuse
Angina
Arthritis
Asthma
Blood Disorder
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Dizziness/Fainting
Emphysema
Epilepsy/Seizures
Frequent Headaches
Gag Reflex
Hay Fever
Head Injuries
Hearing Disabled
Heart Attack
Heart Murmur
Hemophilia
Please select each Medical Condition that is applicable for you!
Known Medical Conditions cont'd
Hepatitis A/B/C
High Blood Pressure
HIV/AIDS
Joint Replacement (hip, knee, etc)
Kidney Disease
Liver Disease
Low Blood Pressure
Lung Disease/ Tuberculosis
Mental Disorder
Mitral Valve Prolapse
Multiple Sclerosis
Pacemaker
Radiation Therapy
Respiratory Problems
Sinus Problem
STD
Stomach/Intestinal Problems
Stroke
Thyroid Disorder
Ulcer
Other
If Other selected, please specify:
*
Do you have any allergies to medication or substances?
*
Yes
No
What Allergies do you have?
Are you taking any prescription medication or herbal remedies?
*
Yes
No
Please list off your medications
*
Do you need to be medicated with antibiotics prior to dental treatment
*
Yes
No
Do you smoke or use chewing tobacco?
*
Yes
No
Have you ever been treated for any other illness not listed above?
*
Yes
No
If Yes selected, please specify:
*
Are you pregnant and/or nursing?
*
Pregnant
Nursing
No
How far along is your pregnancy?
*
Have you recently been under the care of a physician?
*
Yes
No
Name of Physician
*
Physician's Phone Number
When was your last visit with the physician?
*
Current Health Condition
*
Excellent
Good
Fair
Poor
Is there any other information you want to tell us?
Consent
*
I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize Erin Ridge Dental to preform any necessary dental services that I may need.
I am aware of Erin Ridge Dental's cancellation policy which states that short notice cancellations within 48 business hours or failure to come for appointments may result in a $150 fee.
Signature
*
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