New Patient Form Download Form

Patient Full Name *:
Today's Date *:
Gender *:
Male       Female      
Married       Single       Child       Other      
Birth Date *:
Name of Spouse :
Names of Children :
Phone (Home) :
Phone (Work) :
Ext :
Best time to call :
Mobile *:
Email *:
Address  
Street :
Apartment # :
City :
Province :
Postal Code :

Health Information

  
Name of Previous Dentist :
Dentist Telephone Number :
Date of Last Dental Visit :
Reason for this visit :
Upload Document :
Preferred appointment times *:
Morning    Afternoon    Evening    Any Time
 
M    T    W    T    F    S

Have you ever had any of the following? Please check those that apply:
AIDS / HIV
Anemia
Angina Pectoris
Anorexia Nervosa
Artificial Heart valve
Arthritis/Rheumatism
Artificial Joints (hips, knees)
Asthma
Blood Disease
Bronchitis
Bulimia
Cancer
Circulation Problems
Congenital Heart Lesions
Cortisone/steroid
Chemotherapy/Radiation
Diabetes
Dizziness
Drug/alcohol dependency
Emphysema
Epilepsy
Excessive Bleeding
Fainting
 Glaucoma
Glandular disorder
Growths
Head/neck Injuries
Heart Disease/attack
Heart Murmur
Heart Rhythm Disorder
Mitral Valve Prolapse
Migraine Headaches
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
Hodgkin's disease
Hyper/hypo Glycemia
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung disease
Malignant hyperthermia
Mental/nervous disorders
Organ transplant/implant
Psychiatric disorder
Pacemaker
 Recreational Drug use
Respiratory Problems
Rheumatic Scarlet fever
Sickle Cell Disease
Sinus Problems
Stomach Problems
Stroke
Thyroid Condition
Tuberculosis
Ulcers/Tumors
Venereal Disease
Sleep Apnea


FOR WOMEN ONLY:
Are you breast feeding ?
Yes     No    
Are you pregnant ?:
Yes     No    
Due Date:

Adverse effects to any of the following:

  
Penicillin
Sulfonamide
Aspirin
 Barbiturates
Codeine
Darvon
 Local Anaesthetic
None
Other
Allergies (hay fever, latex, etc.) *:
Please list your Medications *:
Family history of adverse anesthetic outcomes *:
No       Yes      
Do you have bad breath or a bad taste in your mouth? *:
No       Yes      
Do your jaws crack, pop, or grate when you open widely? *:
No       Yes      
Are you satisfied with your teeth? *:
No       Yes      
Please explain :
Have you ever had any complications following dental treatment? *:
No       Yes      
Please explain :
Have been to a hospital or needed emergency care during the past two years? *:
No       Yes      
Please explain :
Are you now under the care of a physician? *:
No       Yes      
Please explain :
Name of Physician :
Phone :
Do you have any health problems that need further clarification? :
Do you smoke? How much per day? :

Referral Information

  
Whom may we thank for referring you to our practice? *: Another patient
Medical Walk in
Yellow Pages
Newsletter
Website
Live near by
Road Sign
Newspaper
Pharmacy
Other

Special Concerns:

 
Are you nervous about dental treatment? *:
No       Yes      
Would you like more information on teeth whitening? *:
No       Yes      
Would you like more information on braces? *:
No       Yes      
Are you aware of night time tooth grinding? *:
No       Yes      
Do you require a sports mouth guard? *:
No       Yes      

Insurance Holder's Information

Primary Insurance Plans
Name of Insured :
Is insured a patient? :
No       Yes      
Insured's Birth Date :
ID/Cert # :
Group # :
Insurance Plan Provider :
Insured's Employer Name :
Patient's relationship to insured :
Self
Spouse
Child
Other

Secondary Insurance Plans
Name of Insured :
Is insured a patient? :
No       Yes      
Insured's Birth Date :
ID/Cert # :
Group # :
Insurance Plan Provider :
Insured's Employer Name :
Patient's relationship to insured :
Self
Spouse
Child
Other

Financial Polices

Your insurance benefits are between you, your employer and your insurance company. Any benefit difference (deductible, fee guide, ineligible service or co-payment) is your responsibility.

A service charge of 1½% per month (18% per annum) on the unpaid balance may be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

All estimates for approximate.

Privacy act:

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. The dentist will review the questions and explain any that you do not understand. I understand that Glenashton Dental Office has a privacy act & will take the steps to protect my information. I know that your office has a Privacy Code, and I can ask to see the code at any time. I agree that Dr.Harbans Singh Bamrah/ Glenashton Dental Centre can collect use and disclose personal information about myself as set out in the privacy act. I hereby assign my benefits, payable from claims submitted electronically to Dr. Harbans S. Bamrah and authorize payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.

General Release

I, the undersigned, certify that all of the information I have completed is correct and that I have not knowingly omitted data. I understand that the information contained in the medical and dental history is important to my treatment and if I ever have any change in my health, I will inform the doctors at the next appointment without fail. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my treatment or dental diagnostic procedures. 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 have read the above conditions of treatment and payment and agree to their content.

Signature of patient, parent, guardian, or guarantor of payments *:
Date *:
Printed Name of patient, parent, guardian, or guarantor *:
Dentist Signature :