Patient Forms - Danforth Neighbourhood Dental Centre

Call us at (416) 466-8003

643 Danforth Ave
Toronto, ON M4K 1R2

We are pleased to welcome you to our practice, and hope to provide you, your family, relatives and friends with the highest quality of dental care.

In order to render the best professional care it is necessary that we become acquainted with the vital information related to each patient. Of course all information is strictly confidential. We appreciate your cooperation in filling out this form carefully and accurately.

PATIENT INFORMATION

A parent or guardian will be responsible for decisions on my treatment: Yes | No

Title:

Gender:

Your Name:

Preferred Name:

Pronounciation:

Date of Birth:

Preferred Pronouns:

Address:

CONTACT INFORMATION

Emergency Contact:

Phone Number:

Family Doctor:

Phone Number:

Who may we thank for referring you to our office? (Please put N/A if no referring doctor)

Phone Number:

INSURANCE INFORMATION

Methods of Payment

Cash
Debit
VISA
Mastercard
Insurance

Person Responsible for Payment

Self
Spouse
Parent/Guardian
Other

Do you have Dental Insurance?* Yes | No
If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Information

Policy Holder's Name:

Insurance Provider

Insurance Year End: (usually Dec. 31)

% Coverage For:

Secondary Insurance Information (if applicable)

Policy Holder's Name:

Insurance Provider

Insurance Year End: (usually Dec. 31)

% Coverage For:

Medical History

Please select yes or no to the following:

Are you presently being treated by a physician?*

If yes, please specify:

Are you taking any medications, pills, drugs, or medicine?

If yes, please list:

Do you suffer from any allergies (hay fever, latex, etc)?

If yes, to what?:

Do any allergic reactions result in headaches, shortness of breath, chest constriction or nausea?

If yes, to what?:

Allergies: Have you ever had a reaction to any of the following?*

Have you ever been warned against using any other medications?

If yes, please specify:

Have you ever taken prolonged medical or non-medical drugs?

If yes, please specify:

Do you have any medical implants?

If yes, please specify:

Do you bruise easily or have prolonged bleeding?

Have you ever fainted, had shortness of breath, or chest pains?

If yes, please specify:

Do your ankles swell?

Do you experience frequent headaches?

Do you have any other disease condition or problem that your doctor should know about?

If yes, please specify:

Do you smoke?

If yes, how many per day?:

Women, are you currently pregnant?

If yes, when are you due?:

Are you using birth control?

Do you have any of the following:

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Is there anything else we should know about your health?

Dental History

What is the reason for this visit? Emergency Examination Cleaning Other:

How frequently do you see your dentist? Every 3-6 months Annually Other:

What is the Primary reason for your visit?

Date of your last dental visit?

Date of your last X-Ray?

How often do you brush per day?

How often do you floss per day?

Do you take any pre-medications for dental treatment?

If yes, please specify:

Are your teeth sensitive?

If yes, please specify:

Have you had any past Injury, x-ray therapy, or surgery to your face or jaw?

If yes, please specify:

Does your Jaw pop when opened widely?

If yes, please specify:

Does your mouth hurt when clenched?

If yes, please specify:

Do you experience any pain in your jaw joins or do you suffer from migraines?

If yes, please specify:

Have you had:

Braces Oral surgery Gum treatment Root canal

Have you ever experienced growths or sore spots in your mouth, if so where?

If yes, please specify:

Are you satisfied with the overall appearance of your teeth?

General Release:

I 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 I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine 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.

Patient Name:

Today's Date:

Patient Initials: