epif

NEW PATIENT FORM

Your cooperation in completing this questionnaire is essential to provide you with safe and appropriate dental care. All information is strictly confidential. A member of our team will be able to assist you with the completion of this form if necessary.

FIRST NAME *

LAST NAME *

PREFERRED NAME:

BIRTHDATE (DD/MM/YY):

SEX/GENDER:

HOME ADDRESS (No, STREET, CITY, PROVINCE):

POSTAL CODE:

HOME PHONE:

OTHER PHONE:

CONTACT EMAIL:

What is your preferred contact method?

Call Email Text

IN CASE OF EMERGENCY NOTIFY:

RELATION:

PHONE:

FAMILY PHYSICIAN:

PHONE:

NAME OF GENERAL DENTIST /SPECIALIST:

PHONE OR ADDRESS:

CAREGIVER/GUARDIAN INFORMATION (IF APPLICABLE):

FIRST NAME

LAST NAME

RELATION:

CONTACT EMAIL:

Office Policy Your appointment time will be reserved for you. If you are unable to keep the appointment, we will require 48 hour’s notice, otherwise it may be necessary to charge for the time lost.

INSURANCE INFORMATION (IF THE PATIENT HAS A DENTAL PLAN, PLEASE COMPLETE THE FOLLOWING:

SUBSCRIBER:

RELATION:

DATE OF BIRTH OF PLAN MEMBER:

INSURANCE CO:

POLICY PLAN #:

DIVISION/SECT. #:

SUBSCRIBER ID:

SUBSCRIBER: (SECONDARY)

SUBSCRIBER:

RELATION:

DATE OF BIRTH OF PLAN MEMBER:

INSURANCE CO:

POLICY PLAN #:

DIVISION/SECT. #:

SUBSCRIBER ID:

FIRST NAME

LAST NAME

MEDICAL HISTORY (PLEASE SELECT YES OR NO TO EACH QUESTION)

Do you have any health problems?.

Yes No

If yes, please provide details:

Has there been any change in your general health or weight in the past year?

Yes No

If yes, please explain:

Are you currently being treated for any medical condition or have been treated in the last year?

Yes No

If yes, please explain:

When was the last time you had a medical examination?

Where any problems identified?

Yes No

If yes, please explain:

Have you been hospitalized for any illnesses or operations?

Yes No

If yes, please provide details:

Are you taking any medications, non-prescription drugs, homeopathic or herbal supplements, or hormones of any kind?.

Yes No

If yes, please list and provide reason for taking:_

Do you have any allergies or reactions to any medications, latex/rubber derived products, other (e.g. seasonal, foods, dyes):

Yes No

If yes, please provide details:

Have you had an adverse reaction to any dental materials, injections or local anaesthetic?

Yes No

If yes, please explain:

Do you have or have you ever had a replacement or a 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 No

If yes, please explain:

Do you have a prosthetic or artificial joint?

Yes No

If yes, please explain:

Have you been advised to take a pre-medication (e.g. antibiotics) prior to dental treatment?

Yes No

If yes, please explain:

Do you have any conditions or have undergone therapies that could affect your immune system? (Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)

Yes No

If yes, please provide details:

Have you ever had hepatitis, jaundice, liver disease, or gastrointestinal disorders?

Yes No

If yes, please explain:

Do you have a bleeding problem, bleeding disorder, bruising tendency, have had a blood transfusion, or take blood thinners?

Yes No

If yes, please explain:

Do you have any or have you ever had any of the following (check all that apply)?

Please provide details for any conditions selected above

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

Yes No

If yes, please explain:

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

Yes No

Do you smoke, vape, use e-cigarettes or chew tobacco products?

Yes No

Are you pregnant?.

Yes No

If yes, what is the expected delivery date:

Are you breastfeeding?

Yes No

Do you identify as a person with a disability?

Yes No

If yes, please explain:

Have you had previous problems with dental treatment?

Yes No

Are you nervous/anxious/fearful during dental treatment?

Yes No

Please list any other information you feel we should have to provide you with the best possible care:

Reviewed by Dentist

Date

PATIENT PARENT GUARDIAN CAREGIVER *

Date*