Please take a moment to let us know about your medical and dental history so we may serve you in a way that takes into consideration your overall health and well-being.

PATIENT NAME:*

First Last

PREFERRED NAME:

BIRTHDAY*

SEX/GENDER:*

SCHOOL/OCCUPATION:*

HOME ADDRESS:*

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

HOME PHONE:*

OTHER PHONE:

CONTACT EMAIL:*

May we leave a voicemail regarding your appointment numbers?*

Yes

Are you likely to be available on short notice for future appointments or changes?*

Yes

IN CASE OF EMERGENCY

IN CASE OF EMERGENCY NOTIFY:

RELATION:

PHONE:

FAMILY PHYSICIAN:

PHONE:

PREVIOUS DENTIST OR OFFICE:

CONTACT INFORMATION:

PARENT/GUARDIAN/CAREGIVER 1 INFORMATION:

NAME:

First Last

RELATION:

ADDRESS(STREET,CITY,PROVINCE):

PHONE:

OCCUPATION:

WORK PHONE:

PARENT/GUARDIAN/CAREGIVER 2 INFORMATION:

(IF DIFFERENT THAN ABOVE)

NAME:

First Last

RELATION:

ADDRESS(STREET,CITY,PROVINCE):

PHONE:

OCCUPATION:

WORK PHONE:

PLEASE LIST ANY OTHER PERSONS WHO MAY HAVE ACCESS TO THIS FILE

(E.G. SCHEDULING APPOINTMENTS)

NAME:

RELATION:

INSURANCE INFORMATION

Do you have insurance?*

Yes

IF THE PATIENT HAS A DENTAL PLAN, PLEASE COMPLETE THE FOLLOWING

SUBSCRIBER:

DATE OF BIRTH:

RELATION:

INSURANCE CO:

POLICY PLAN # :

DIVISION/SECT. # :

SUBSCRIBER ID:

EMPLOYER:

SUBSCRIBER: (SECONDARY)

DATE OF BIRTH:

INSURANCE CO:

POLICY PLAN # :

DIVISION/SECT. # :

SUBSCRIBER ID:

EMPLOYER:

PATIENT DENTAL HISTORY

Reason for today's visit:*

Do you have a dental problem that needs to be addresses as soon as possible?*

Yes

Have you been visiting the dentist regularly?*

Yes

Last dental visit

Doctor or Clinic Name

Last Cleaning

Last X-rays

How often do you brush your teeth?*

How often do you floss your teeth?*

Do your gums bleed regularly?*

Yes

Are your teeth sensitive to*

Hot

Cold

Biting

Sweets

Sour

N/A

Do you feel any pain in your teeth?*

Yes

Have you ever had any head, neck, or jaw injuries/surgery?*

Yes

Do you have dry mouth or difficulty swallowing?*

Yes

Do you snore or have sleep apnea?*

Yes

Does your jaw crack, click or pop when opened widely?*

Yes

Do you grind or clench your teeth during the day or night?*

Yes

Do you bite your lips/cheeks frequently?*

Yes

Have you ever experienced any growths, lumps or sore spots in your mouth?*

Yes

Have you noticed any loosening/movement of your teeth?*

Yes

Have you had periodontal (gum) treatment?*

Yes

Have you had orthodontic (braces) treatment?*

Yes

Have you ever had treatment by a dental specialist?*

Yes

Have you had previous problems with dental treatment?*

Yes

Are you satisfied with the appearance of your teeth?*

Yes

Are you nervous/anxious/fearful during dental treatment?*

Yes

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

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

Do you have any health problems?*

Yes

If yes, please provide details:

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

Yes

If yes, please explain:

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

Yes

If yes, please explain:

When was the last time you had a medical examination?*

Were any problems identified?*

Yes

If yes, please explain:

Have you ever been hospitalized for any illnesses or operations?*

Yes

If yes, please provide details:

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

Yes

If yes, please list and provide reason for taking:

Do you have any allergies or reactions? (If yes, please list using the categories below)*

Yes

Medications

Latex/rubber derived products

Other (e.g. seasonal, foods, dyes)

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

Yes

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

If yes, please explain:

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

Yes

If yes, please explain:

Do you have a prosthetic or artificial joint?*

Yes

If yes, please provide details

Do you have any or have you ever had any of the following:*

Yes

Check all that apply:

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

Yes

If yes, please explain:

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

Yes

Are you pregnant?*

Yes

If yes, what is the expected delivery date:

Are you breastfeeding?*

Yes

Do you identify as a person with a disability?*

Yes

If yes, please explain:

Is there any additional information related to your health that has not been addressed above?

Yes

If so, please advise:

HOW DID YOU HEAR ABOUT US?

I hereby certify that I have read and understand the previous information and that it is true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. I will keep the dental office updated with any changes to my health and/or medications and allergies.

Authorization

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. Privacy of our patient’s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft, and unauthorized access.

Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes clinical records, x-rays, study models, photographs of your teeth, mouth, smile, face, and general health information obtained from a medical history review, insurance information, phone numbers and addresses. Clinical information, photographs and x-rays may also be used for long-term follow-up, research purposes, anonymously on our website smile gallery, as well as for education or teaching purposes.

Your personal information shall be disclosed to only those who have a need to know and specific information. Disclosed shall be restricted to only that information relevant to what the recipients need to know. Those who have a need to know include referring dentist, other dental specialists, physicians, dental laboratories, and dental insurance companies. The security and privacy of your personal information is one of our primary concerns and we have taken every precaution to protect it.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).

I am also aware of the cancellation policy of True Dental. 48 hours notice for cancellation of appointments is required in which case no charge will be made. Short notice and no show appointments will be charged at $50.00 per half hour. Please call the office and speak with a team member to reschedule.

Signature of patient, parent, or guardian:

Signature*

Date

Relationship to patient:

CAPTCHA

IN CASE OF EMERGENCY

PARENT/GUARDIAN/CAREGIVER 1 INFORMATION:

PARENT/GUARDIAN/CAREGIVER 2 INFORMATION:

PLEASE LIST ANY OTHER PERSONS WHO MAY HAVE ACCESS TO THIS FILE

INSURANCE INFORMATION

PATIENT DENTAL HISTORY

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

Authorization

Signature of patient, parent, or guardian:

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