New Dental Patient Intake | Modev Media | Clinic Forms

Step 1 of 5 - PATIENT INFORMATION

20%

Dental Intake Form

Patient Information
Name*
First Last
Birthdate*
YYYY dash MM dash DD
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Work Phone
Home Phone
Email*
Drivers License #
How did you hear about our office?
Emergency Contact
Name
First Last
Phone
Family Doctor
Name
First Last
Phone

Insurance Information
Do you have insurance?
- Yes
- No
Primary Insurance
Are you the policy holder?
- Yes
- No
Policy Holder
First Last
Birthdate
YYYY dash MM dash DD
This field is hidden when viewing the form
Insurance Company
Employer
Policy #
Cert/ID #
Basic (A) %
Major (B) %
Yearly Max
Do you have a secondary insurance policy?
- Yes
- No
Secondary Insurance
Are you the policy holder?
- Yes
- No
Policy Holder
First Last
Birthdate
YYYY dash MM dash DD
Insurance Company
Employer
Policy #
Cert/ID #
Basic (A) %
Major (B) %
Yearly Max

Medical History

This information is necessary for your dental care and will remain confidential.
Are you currently under the care of a physician due to a specific medical condition?*
- Yes
- No
Are you taking any prescription or non-prescription medications?*
- Yes
- No

Please list the medication and reason for the medication

Medication	Reason

Are you allergic to or have had an adverse reaction to any medications?*
- Yes
- No
Please select the medication that you are allergic to or had a reaction to
- Aspirin
- Barbiturates
- Codeine
- Erythromycin
- Local Anesthetic
- Penicillin
- Sulfa
- Valium
- Other
Other
Have you ever been warned against taking any other medications?*
- Yes
- No
Please specify:
Do you suffer from any allergies (hay fever, latex, etc.)?*
- Yes
- No
Please specify:
Do you bruise easily or have prolonged bleeding?*
- Yes
- No
Do you smoke or use tobacco products?*
- Yes
- No
How much per day?
Are you pregnant?
- Yes
- No
What is your due date?
DD slash MM slash YYYY
Do you have or have you ever had any of the following?
- Artificial Joints
- Artificial Heart Valve
- Blood Disorder
- Cancer
- Diabetes
- Emphysema
- Heart Disease
- Heart Surgery
- Heart Murmur
- Hepatitis A B C
- High Blood Pressure
- HIV Positive (AIDS)
- Kidney Disease
- Low Blood Pressure
- Liver Disease
- Lung Disease
- STD
- Migraines
- Radiation/Chemotherapy TX
- Rheumatic Fever
- Mental/Nervous Disorder
- Stroke
- Thyroid Disease
Do you have any disease, condition, or problem not listed?

Dental History
What is the reason for today’s visit?
How frequently do you see a dentist?
- 3 - 6 Months
- Annually
- Other
When was your last dental visit?
When was your last dental X-Ray?
How often do you brush?
How often do you floss?
Are your teeth sensitive to
- Cold
- Sweets
- Heat
- Other
Do your gums bleed when
- Brushing
- Flossing
- Never
Do you grind or clench your teeth?
- Yes
- No
Are you satisfied with the way your teeth feel?
- Yes
- No
- Unsure
Have you ever had any problems with previous dental treatments? Please explain
What, if anything, would you change about your smile?

Consent
Consent*
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed 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 care providers as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine the 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.*
Signature*
Relationship to patient
- Self
- Parent
- Guardian

Modev Media
9906 Hedley Drive
Ilderton, Ontario N0M 2A0

Tel: 5198786880 Fax: 5198786880
[email protected]