First Name
Last Name
Preferred Name
Birthday
Age
GenderMaleFemalePrefer not to say
Address
City
Province
Postal Code
Home Phone
Cell Phone
Business Phone
Email
Occupation
Employer
Who may we thank for your referral?
Are you currently under any medical treatment?
Date of last physical
Doctor’s name
Are you taking any medications including over the counter medications and herbal supplements?
YesNo
Please specify
Any allergies, or allergies to medications or latex?
Abnormal bleeding / HemophiliaEpilepsyAcid refluxHeart valve replacementAnemiaHepatitis / HIVArthritisHigh / Low blood pressureAsthma or Hay feverImmune disordersArtificial JointsKidney diseaseLiver diseaseChemo / RadiationMental disordersCold soresPacemakerDiabetesRespiratory problems / COPDDizziness / FaintingSinus problemsDrug / Alcohol DependencySteroid therapyStroke / Heart attack / Heart Disease
Are you have cancer? YesNo
(Type Of cancer?)
Are you have any surgeries? YesNo
(Surgery Date?)
Is there any other medical information we need to know?
Are you taking birth control pills?
Are you pregnant?
Due date:
Are you nursing?
Do you have any pain? If so where?
How often do you see a dentist?
Name of previous dentist?
How often do you brush your teeth?
How often do you floss?
Do your gums bleed easily?YesNo
Are your teeth sensitive to the following?HotColdSweetsBiting
Any concerns with bad breath?
Do you have pain in your jaw joints? clicking / cracking jaws when opening? Have you been diagnosed with TMJ or have trouble with long dental appointments? Please describe:
Do you clench or grind your teeth? YesNo
Do you snore? YesNo
Have you ever had a sleep study? YesNo
Do you smoke? YesNo
Have you had any previous problems with dental treatment? YesNo
Are you nervous during dental treatment? YesNo
Please rate on a scale from 1-10 with 10 being the highest.
Do you have any problems getting numb from dental treatment? YesNo
Is there anything you would like to change about your smile?
Are you interested in more information on any of the following services?
Cosmetic DentistryInvisalignWhiteningBotox
Patient Signature (Parents if a minor)
Date
Follows Fee Guide | Accepts CDCP
