Digital New Patient Form

Your First Name (required) Your Last Name (required)
Address No. / Street (required) City (required) Province (required) Postal Code (required) Cell Phone No. (required) Your Email (required)
Emergency Contact Name Phone
Dental Information Name of dental insurance coverage, if available Name of previous dentist and the date of last visit Date of last X-ray Any issues or conditions you have; Gum BleedingTeeth Cold SensitivityTeeth Sweets or Sour SensitivityPain on ChewingHead or Jaw InjuryJaw Clicking/Pain/Opening IssueLoose TeethFood Trap Between TeethWearing DentureHaving Dental ImplantUnhappy with Your SmilePast Orthodontic Treatment

Medical History/ Any Health Issues You Had or Have

Anesthetic reactionArthritisArtificial JointsArtificial ValveAsthmaHigh Blood PressureBruise EasilyCancerChange in AppetiteChemo/ radiotherapyChest PainClenching/GrindingCold SoreCongenital Heart ConditionCortisone/ Steroid TherapyDiabetesDifficulty SwallowingEarachesEpilepsy/ SeizureFeel ThirstyVomitingHeadacheHeart AttackHeart MurmurHepatitisAIDS/ HIVInfectious DiseaseKidney ProblemLung/ Breathing ProblemMitral Valve ProlapseNervous/ Mental ProblemPacemakerProlong BleedingPersistent CoughPainful JointsRheumatic FeverSinus ProblemTendency to FaintThyroid DiseaseTumorVenereal DiseaseSmokingStrokeStomach UlcerTuberculosisDrug UseNeed for Antibiotic Premedication Before Dental TreatmentPregnancy List of any other health issues you have or had not listed above List of all medications you are taking Allergy to any medication /product How did you hear about us?
ACKNOWLEDGMENT AND CONSENT TO DENTAL TREATMENT

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Signature (Please sign below using touch screen devices or your mouse):