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

Name of dental insurance coverage, if available

Name of previous dentist and the date of last visit

Any health conditions you have or had:

Anesthetic reactionArthritisArtificial JointsArtificial ValveAsthmaBlood 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 DiseaseSmokingDrug UsePregnancy

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
While we offer the best possible treatment(s), some complications may arise post-operatively. These complications included but not limited to : -Neglect to inform dentist about any medical condition: Allergic reaction to antibiotic, codeine, dental materials or latex, drug interaction, increasing risk for people with heart condition, high blood pressure, diabetes, thyroid problem, pregnant women and the ones who are taking some medications. -Refusal to take X-Ray: Misdiagnosing or not diagnosing cavities, periodontal (gum) diseases, some systemic diseases and/or jaw cysts or tumors. -Local anesthesia: Allergic reaction , drug interaction, temporary and/or permanent numbness or altered sensation of the lower lip, chin, gum, or tongue. -Teeth cleaning and whitening: Sensitivity, root exposure. -Oral or periodontal (gum) surgery: Bleeding, swelling, discomfort, sensitivity, dry socket, infection, temporary and/or permanent numbness or altered sensation of the lower lip, chin, gums, or tongue, damage to fillings and/or crowns of adjacent teeth, opening of sinus, root exposure. Shifting of adjacent teeth and over eruption of opposing teeth in case of tooth extraction. Extraction of baby teeth may result in lack of enough space for eruption of permanent teeth requiring orthodontic treatment in future. -Fillings and crown/bridges: Tooth sensitivity due to irritation during cavity removal or tooth preparation which may subsequently need root canal treatment. - Fracture of filling due to lack of enough tooth structure. Losing crowns/bridges due to lack of enough retention through tooth structure or lack of intra canal / para pulpal post(s). Starting of new cavities at the margin of fillings/crowns due to inadequate oral hygiene. -Root canal treatment (RCT): Pain mostly on touch or bite, infection flare up, discoloration of tooth, fracture of tooth due to dehydration or lack of full coverage (crown), uncompleted cleaning of canal(s) due to unusual anatomy or unusual number of canals or calcified canal(s). - Dentures: Having no teeth from extraction date till delivery of denture, sore spots requiring multiple post insertion adjustment, loose dentures due to lack of support through bone/tissue/remaining teeth which may require relining/rebasing/implant, discoloration or fracture of denture due to improper maintenance. - Use of digital communication: I consent to communicate my personal and health information using digital medias such as email, text and online forms. By submitting this form online, I confirm that I agree with such transmission of my information to or from ABAN Yaletown Dental exclusively for any dental and medical related communication both for now and in future. Use of such a digital communication between our office and you can be revoked at any time by providing a written notice by you. I, hereby consent to the dental treatment agreed upon and that I am responsible for payment of the corresponding fees in regard to my planned treatment and/or any necessary additional non-planned treatment(s) regardless of whether my dental coverage covers it. All information provided here are correct to the best of my knowledge. I understand that a possibility of complications exists for each treatment as some of them outlined above. I hereby consent ABAN Yaletown Dental and associated dentist(s) to perform all necessary dental treatments. I hereby authorize ABAN Yaletown Dental to collect and share information regarding my dental benefit coverage with my Dental Insurance Company(s) as needed for the purpose of direct billing to my insurance company(s), if applied.
I acknowledge and consent to above