Patient's Name:

Date of Birth:

Address:

Home Phone:

Business Phone:

E-mail address:

Business Address:

Occupation:

Name of spouse,
parent or nearest relative:

Employer:

Business Phone of Employer:

If a patient is a minor,
who is legally responsible:

Referring Dentist:

Family Physician:

Do you require an insurance form?
(If yes, provide name of insurance company)

 

Health History:

Are you in good health?

Have you been treated by a physician during the past 5 years?

Are you sensitive or allergic to Novacaine, Penicillin, Codeine,
Aspirin or any other medication?

Are you taking any medication?

Have you ever had an unfavourable reaction following dental treatment?

Have you ever had excessive bleeding requiring special treatment?

Have you ever had any of the following illnesses:

Stroke	Heart Murmur	Mitral Valve Prolapse (MVP)	Artificial Body Parts	High Blood Pressure
Rheumatic Fever	Dizziness	Asthma	Hepatitis A	Hepatitis B
Hepatitis C	HIV+	Jaundice	Tuberculosis	Diabetes
Venereal Disease	AIDS	Kidney Disease	Epilepsy	Nervous Disorders

 

Have you had any serious illness?

Have you ever had root canal treatment?

Female patients: are you pregnant?

I, the undersigned, being the patient, parent or guardian of the above minor patient, consent to the performing of whatever procedure may be determined necessary or advisable, in the opinion of the Doctor. A report of treatment will be sent to my referring dentist. I also understand that upon completion of root canal therapy in this office I will be referred to my general dentist for permanent restoration such as crown, cap, jacket, onlay or filling.

I understand that the total payment of the dental service is my responsibility and not that of the insurance company. Payment is due when services are rendered.

Patient Name:


Authorization/Electronic Confirmation
(please type your name again):