Dental Specialty Group North Toronto North York Kitchener Periodontal

Dental Specialty Group Toronto North York Dentist

NEW PATIENT REGISTRATION

Patient Information

patient title

Patient sex

Male

Female

Height :

Weight :

First Name :(Required)

Patient Cell # :

Last Name :(Required)

Patient Home # :

Birth Date :

Age :

Patient Business # :

Ext :

Street Address :

Current Dentist :

Suite / Unit :

Orthodontist :

City / Postal Code :

Family Physician :

Patient Occupation :

Family Physician # :

Patient Health Card :

Medical Specialist :

Patient Email :

Medical Specialist # :

Reason for your visit ?

Pharmacy # :

Have you been referred by someone other than your dentist?

Yes

If yes, who may we thank ?

Have you or a family member ever been a patient of our practice in the past ?

Patients under the age of 18 should be accompanied by a parent/legal guardian during consultation. To avoid appointment cancellation, please advise our patient care coordinators if a parent/legal guardian cannot be present.

Insurance Information

Workplace :

Primary Insurance Co :

Secondary Insurance Co :

Group / Policy # :

Certificate ID # :

Subscriber's Name :

Subscriber's Birth Date :

Relationship to Patient :

Your visits to this office are NOT covered by OHIP. This office does not take payment from your insurance company.

Who will be financially responsible for your account? (If patient is under the age of 18)

First Name :

Cell # :

Last Name :

Home # :

Birth Date :

Business # :

Ext

Relationship to patient :

Email :

Full Address (if different than patient) :

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact (Must be completed)

Full Name :(Required)

Cell # :(Required)

Relationship to Patient :(Required)

Other # :

Medical History Questionnaire

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 surgeon will review these questions and explain any that you do not understand.

1. Are you being treated for any medical condition at the present or within the past year?

Yes

If yes, please explain.

2. When was your last medical checkup ?

3. Has there been any change in your general health in the past year?

Yes

If yes, please explain.

4. Are you taking any medication, non-prescription drugs, or herbal supplements of any kind?

Yes

If yes, please list. (to add more, click + )

5. Do you have any allergies to Medications, Latex/Rubber products, Other (eg. hay fever, foods, shellfish )?

Yes

If yes, please list. (to add more, click + )

6. Have you ever had a peculiar or adverse reaction to any medicines, injections, or anesthesia?

Yes

If yes, please explain.

7. Do you have or have you ever had asthma?

Yes

If yes, please explain.

8. Do you have or have you ever had any heart or blood pressure problems ?

Yes

If yes, please explain.

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

Yes

If yes, please explain.

10. Do you have a prosthetic or artificial joint?

Yes

If yes, please note the date of surgery.

11. Are you currently being treated for low bone density or osteoporosis?

Yes

If yes, please explain.

12. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy, organ transplant)?

Yes

If yes, please explain.

13. Have you ever been hospitalized for operations/surgeries requiring anesthesia?

Yes

If yes, please explain and note the date.

14. Do you have or have you ever been prescribed the medication Ozempic (Semaglutide)?

Yes

If yes, please explain.

15. Please Indicate if you have ever taken or currently take any of the following bone medications?

Fosamax choice

Fosamax (alendronate)

Actonel choice

Actonel (risedronate)

Prolia choice

Prolia (denosumab)

Other:

16. Please Indicate if you have ever taken or currently take any of the following blood thinning medications?

blood thinning 1

Xarelto (rivaroxaban)

Coumadin (warfarin)

blood thinning 1

Eliquis (apixaban)

Aspirin (ASA)

blood thinning 1

Pradaxa (dabigatran)

Plavix (clopidogrel)

Other:

17. Please Indicate if you have had or currently have any of the conditions below?

other conditions

18. Are there any conditions or diseases not listed above that you have had or currently have?

Yes

If yes, please list.

19. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?

Yes

If yes, please explain.

20. Have you or anyone in your family ever had an unusual or serious reaction to general anesthesia (i.e. malignant hyperthermia)?

Yes

If yes, please explain.

21. Do you smoke or chew tobacco products?

Yes

If yes, how often.

22. Do you have anything removable in your mouth (i.e. denture, piercing)?

Yes

If yes, please list.

23. Are you breastfeeding or pregnant?

Yes

If pregnant, please indicate the expected delivery date.

24. Are you nervous during dental treatment?

Yes

Permission to Give Access

If you wish to give a family member or friend the ability to contact Dental Specialty Group on your behalf, please provide us with your advocate's full name, their relationship to you and indicate the appropriate box(es) with what you'd like the individual to have access to. This section is mandatory if patient is 16 years of age or older.

Full Name :

Relationship to Patient :

Untitled

Scheduling

Financial/Insurance

Medical Info

Full Name :

Relationship to Patient :

Untitled

Scheduling

Financial/Insurance

Medical Info

Full Name :

Relationship to Patient :

Untitled

Scheduling

Financial/Insurance

Medical Info

Consent to Medical History and Consultation

I hereby state that the above information is, to the best of my knowledge, accurate and complete . If ever there are changes in my health or medications(s), I will inform the doctor without fail. I will not hold my surgeon, or any other member of his/her team, responsible for any errors or omissions that I have made in the completion of this form. I grant permission for my physician, dentist and other healthcare providers involved in my treatment to be contacted by Dental Specialty Group for details and advice. I further authorize the taking of radiographs or other diagnostic measures appropriate for a thorough evaluation.

Patient Signature :

(If 16 years of age or older)

Print Name :

Date :

Parent/Guardian Signature :

Print Name :

Date :

Surgeon Signature :

Date :

Consent to Financial Policy

I am expected to pay in full by credit card, debit, or cash (exact amount - no cheques) for all services rendered on the day of my appointment. I understand that this office does not directly bill my insurance provider. However, I will be provided with claim form(s) that I can submit to my insurance provider for reimbursement to me. I understand and agree with this policy.

Patient Signature :

(If 16 years of age or older)

Print Name :

Date :

Parent/Guardian Signature :

(If parent/guardian will be making payment on behalf of patient)

Print Name :

Date :

Consent to the Collection, Uses and Disclosures of Patient's Personal Health Information

I hereby acknowledge that a copy of this office's policy for Collection , Uses and Disclosures of Patients' Personal Health Information has been made readily accessible to me. I have reviewed the information that explains how this office will use my personal health information, and the steps this office is taking to protect my information. My signature below signifies that Dental Specialty Group can collect, use and disclose my personal health information as set out in the information about the office's privacy

Patient Signature :

(If 16 years of age or older)

Print Name :

Date :

Patient/Guardian Signature :

Print Name :

Date :

CAPTCHA