New Patient Form

Patient's First Name *

Patient's Last Name *

Date of Birth *

Home Address *

Home Phone

Business Phone

Mobile Phone *

Email Address *

Occupation

Business Address

Name of spouse, parent, or nearest relative *

Employer

Business Phone of Employer

If the 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) *

Yes

No

Health History

Are you in good health? *

Yes

No

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

Yes

No

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

Yes

No

Are you taking any medication? *

Yes

No

Have you ever had an unfavourable reaction following dental treatment? *

Yes

No

Have you ever had excessive bleeding requiring special treatment? *

Yes

No

Have you ever had any of the following illnesses?

Have you had any serious illnesses? *

Yes

No

Have you ever had root canal treatment? *

Yes

No

Female Patients: Are you pregnant? *

Yes

No

Patient First Name *

Patient Last Name *

Patient Consent Regarding Treatment & Payment Terms *

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.

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

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