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Patient Information (Please fill all the fields with the accurate info)

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A Parent or Guardian will be responsible for decisions relating my treatment

First Name

Initial

Last Name

Email:

Cell Phone Number

Home Phone Number

Work Phone Number

Address

City

Postal Code

Preferred method of contact

I agree to be added to your Facebook page

I agree to subscribe to your newsletter

Preferred time for appointment (check all that apply)

Preferred day for appointment (check all that apply)

Family Dr:

Family Dr. Contact Number:

Emergency Contact:

How did you hear about us?

Referred by (Insert Name - Patient or Family Doctor)

Date of Birth:

* Please provide your Government ID to verify the Date of Birth at Dentist Office

INSURANCE INFORMATION

Do you have extended health or dental Insurance?

If yes, please provide your card to receptionist, they will make a copy for your file.

DENTAL HISTORY

1. What is the reason for today's visit?

2. When was your last dental visit?

3. Are you teeth sensitive to:

4. Are you teeth sensitive if other please enter:

5. Do your gums bleed when:

6. Do your gums feel swollen or tender?

7. Do you have bad breath or a bad taste in your mouth?

8. Do you have food catch between your teeth?

9. Have you ever had local anaesthetic (freezing)?

If yes, were there any complications? Please specify

10. Have you had any problems with previous dental treatments?

Specify

11. Have you had any of the following:

12. Do you have sleep Apnea?

If yes, are you using any of the following:

13. Are you satisfied with your teeth?:

MEDICAL HISTORY (this information will remain confidential)

1. Are you presently under the care of a physician?

If so explain

2. Have you ever had a serious illness or been hospitalized?

If so explain

3. Are you taking any Drugs or medication at this time?

4. Do you suffer from any allergies (hay fever,latex,etc.)?

If so which ones?

5. Do you bruise easily or have prolonged bleeding?

6. Have you ever fainted, had shortness of breath or chest pains?

7. Have you ever been warned against using any medication?

If so which?

8. Have you ever taken prolonged medical or non-medical drugs?

Please Specify

9. Have you ever had an adverse effect to any of the following?

10. Do you or have you ever had any of the following: Please select appropriate option

Please Specify Other

11. Cycle Status:

Are you pregnant?

Have you reached menopause?

Are you on Oral Contraceptive Pills?

12. Children only: Have you recently had any of the following (approximate date)

GENERAL RELEASE: I, the undersigned, understand that the information contained in the dental and medical history portion of this chart is important to my treatment. I certify that all the information is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine perform necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. i assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

COVID-19 MEDICAL RISK ASSESSMENT SCREENING

Do you currently have a cough, fever, shortness of breath, runny nose, muscle ache or diarrhea?

Have you travelled outside of Canada in last 14 days?

In the past 14 days, have you been in contact with anyone who has screened positive for COVID-19?

Have you had loss of taste / smell in recent days?

If any of your answers for the above questions are "YES" then you need further assessment before you can visit the clinic. Please call on helpline number 811.

NAME:

SIGNATURE:

DATE: 19/06/2022

Patient Information (Please fill all the fields with the accurate info)

COVID-19 MEDICAL RISK ASSESSMENT SCREENING

Bridge West Dental Office

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