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Patient Intake Form
Step
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New Patient Information
First Name
*
Last Name
*
Birth Date
MM slash DD slash YYYY
Email
*
Main Phone
*
Cell Phone (If different than main)
Patient Address
Address
*
City
*
Province
*
Province
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Saskatchewan
Manitoba
Ontario
Quebec
Newfoundland
New Brunswick
Nova Scotia
PEI
NWT
Nunavut
Yukon
Postal Code
*
Emergency Contact Details
Parent or Guardian Name (If Applicable)
Emergency Contact Name
Emergency Contact Number
Patient Dental History
Previous Dentist
Previous Clinic
Phone Number
Date of Last Exam
MM slash DD slash YYYY
Date of Last Cleaning
MM slash DD slash YYYY
Date of Last X-rays
MM slash DD slash YYYY
Do you feel any pain in your teeth?
*
Yes
No
Do your gums bleed while brushing/flossing?
*
Yes
No
Do you have any sores or lumps in/near your mouth?
*
Yes
No
Do you favor one side of your mouth when you eat?
*
Yes
No
Have your gums ever been swollen or tender?
*
Yes
No
Do you have a hyperactive gag reflex?
*
Yes
No
Have you ever had any unusual reaction to fluoride or freezing?
*
Yes
No
Have you had any of the following habits?
Clench or Grind Teeth
Mouth Breath
Bite Your Nails
Snore
Have you ever had any head, neck, or jaw injuries?
*
Yes
No
Please provide details here...
*
Do you have frequent head, neck or shoulder aches?
*
Yes
No
Please provide details here...
*
Have you ever experienced any of the following problems in your jaw?
Clicking
Pain
Difficulty Opening/Closing
Difficulty Chewing
Have you ever had any of the following dental treatment?
Filling
Extractions
Root Canal Treatment
Crown or Bridge
Orthodontic Treatment
Patient Medical History
Your Doctor
Your Medical Clinic
Doctor's Phone Number
Are you taking any medication(s) including non-prescription medicine?
*
Yes
No
what medication(s) are you taking? Please provide a complete list of medication?
Do you have any allergies?
*
Yes
No
please provide details.
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
*
Yes
No
please provide details.
Do you smoke?
Yes
No
Do you wear contact lenses?
Yes
No
Have you ever had any of the following? (Please check all the applicable boxes)
AIDS or HIV Infection
Anemia
Angina
Mental Disorder
Nervous Disorder
Arthritis
Asthma/COPD
Bleeding Problems
Cancer
Cardiac Pacemaker
Cleft Lip or Palate
Chest Pains
Cirrhosis
Cystic Fibrosis
Diabetes
Eating Disorder
Emphysema
Epilepsy/Convulsions
Fainting/Seizures
Fibromyalgia
Glaucoma
Heart Attack
Heart Disease
Heart Murmur
Heart Surgery or Transplant
Hepatitis
High Blood Pressure
Low Blood Pressure
Joint Replacement
Kidney Disease
Leukemia
Liver Disease
Osteoporosis/Osteopenia
Radiation/Chemo Therapy
Respiratory Problems
STD
Sinus Trouble
Stomach Troubles/Ulcers
Stroke
Thyroid Disease
Women Only
Are you pregnant or think you may be pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking oral contraceptives?
Yes
No
Do you have allergies?
Yes
No
please provide details.
Authorization & Agreement Details
Authorization and Release of Information
*
I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator.
I accept
Payment Authorization
*
I (patient, parent or guardian) authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to the patient. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for the payments of all services rendered on my behalf or dependents. I authorize Fort McMurray Dental to immediately process any outstanding balance under $200.00 towards the credit card as indicated below. Any outstanding balances owing that are over $200.00 will be processing in monthly increments of $200.00 until balance is fully paid. I am aware I will be contacted regarding my outstanding balance and any payment not processed within 90 days, unless otherwise discussed with management, will be deemed uncollectable and forwarded to a collection agency.
I accept
Cancellation Policy
*
I agree and am aware of the $50.00 fee if I fail to show to my dental appointment or need to cancel or reschedule an appointment within less than 2 business days.
I accept
Signature of Approval
Print Patient/Guardian Name
Signature
*
Date
780-823-1555
280 Pioneer Road, Unit 318
Spruce Grove AB T7X 3Y3
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