Patient Information Form

Welcome! Thank you for selecting us.

To help us provide you with the highest standard of dental care, please fill out this form completely. All information is strictly confidential. If you need assistance, please ask us and we will be happy to help you.

Office Location *

Personal Information

Prefix

First *

Last *

Date of birth *

Email *

Sex *

Address

Street Address *

City *

Postal Code *

Phone *

Person to contact in case of emergency *

Emergency Contact Number *

Name of family members who are patients at our office

How did you hear about our office?

Whom may we thank for referring you?

Reason for Visit

What bothers you most? (chief complaint)

Do you have dental insurance? *

Insurance Information

BC Care Card # *

If student, name of school & If full time, enter student ID# *

Primary Insurance Company's Name *

Dependent Name *

Dependent Birthday *

Policy holder's name *

Insurance plan(Contract) number *

Insurance ID(Certificate) number *

Policy holder's Birthday *

Relationship to policy holder

Do you have secondary dental insurance? *

Secondary Insurance

Secondary Insurance Company's Name *

Dependent Name (Secondary Insurance) *

Dependent Birthday (Secondary Insurance) *

Policy holder's name (Secondary Insurance) *

Insurance plan(Contract) number(Secondary Insurance)

Insurance ID(Certificate) number (Secondary Insurance)

Policy holder's birthday (Secondary Insurance)

Relationship to policy holder (Secondary Insurance)

Dental History

When did you see a dentist last? And, where(clinic name, location)? *

How frequently do you go to a dental clinic? *

When did you get teeth cleaned in a dental clinic last? *

Have you ever been educated about oral hygiene instructions? *

Have you ever had any complications with local anesthetics? *

Have you had abnormal bleeding after dental procedures before? *

Do you feel some pain around jaw joints when you open your mouth wide? *

Do you easily gag during dental treatment? *

Do you feel any discomfort when you lie down on a dental chair? *

Do you have any difficulty in breathing during dental treatment? *

Please check if you had the following treatments in the past:

Daily Habit Assessment

How often do you brush your teeth per day?

Do you use dental floss? *

Do you grind or clench your teeth? *

Do you habitually chew something like pencils, nails, lips, tongue?

Oral Discomfort Assessment

Do you usually feel your mouth dry? *

Do you have any sensitivity on your teeth (cold, hot, sweet, chew)? *

Do you have gum bleeding? *

Do you feel any discomfort on your jaw or cheeks when you get up in the morning? *

Do you hear any sound from jaw joints when you open and close your mouth? *

Do you have any difficulty in mouth opening or closing? *

Do you have any headache, neckache, or shoulder pain? *

Supplement Assessment

We are happy to talk with you about your dietary issues or your esthetic needs. As orofacial professionals, we can help you with your healthy lives and happy smiles.

Do you want a consultation about your dietary habits or nutritional guides? *

Are you concerned with your bone health? *

Are you taking any dietary supplements to improve or maintain bone health? *

Do you want to change your smile by having dental treatments such as braces and veneers for cosmetic purposes? *

Are you interested in facial esthetics such as BOTOX injection? *

Office Policy

zero *

I have read and fully understand the above office policy statements. I consent to the terms.

Patient Rights and Consent

one *

I have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I have the opportunity to ask any questions and receive answers regarding this Medical/Dental history and I consent to my physician being contacted if necessary. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

two *

I authorize this office to consult with or transfer my dental records to/from a medical doctor, specialist or other dentists if necessary or requested

three *

I authorized the dentist and his or her qualified staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I understand that refusal to do may result in compromised treatment.

four *

I authorize the dentist to perform any or all forms of treatment, medication, and therapy that may be indicated and consent to the use of local anesthetic agents.

five *

As a patient, I understand that I have the right to be advised of the benefits, options, risks, and potential complications of any dental procedure, ask questions and receive complete answers regarding my oral health, and make an informed decision to accept or decline recommended treatment.

six *

I agree that responsibility for payment of dental services by this office for myself or my dependents is mine (whether or not paid by insurance) and payable at the time services are rendered unless other financial arrangements have been made.

Disclosure of photos, x-rays, and models - I consent to the disclosure of photography, filming, recording, models, and x-rays of mine for the purpose of patient education, consultation, advertisement, and publication, provided that my identity is NOT revealed

Signature

Patient or guardian

Date