New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.

About you

Title:
Mr
Mrs
Ms
Dr
Patient Name: *


Your birthday: *
Home address: *
Home phone: *
( ) - -
Cell phone:
( ) - -
Email address: *
Marital Status:
Single
Married
Divorced
Widowed
Other
Employer:
Work phone:
( ) - -
Employer Address:
Family Physician:
Cell phone:
( ) - -
Date of Last Medical Exam:

Spouse, Parent, or Guardian Details

His / Her name:
Employer:
Employer Address:
Home Phone:
( ) - -
Phone (Bus) #:
( ) - -

Emergency Contact Details

Contact Name:
Phone #
( )- -
Whom may we thank for referring you to our practice?
Web page
Newspaper
Flyer
Yellow Pages
Another Patient

Insurance information

Primary Insurance Information

Do you have dental insurance?
Yes No
Name of Insured:
Relation to Insured:
Date of Birth:
Insurance Company :
Group #:
ID #:
Credit Card Type:
Credit Card #:
Exp Date:

Secondary Insurance Information

Do you also fall into another family member’s dental insurance?
Yes No
Name of Insured:
Date of Birth:
Insurance Company :
Group #:
ID #:

Authorization

*
I hereby authorize and request my insurance company to pay directly to the dentist for the services rendered. I understand that I am financially responsible for all dental fees whether or not insurance pays for them. I authorize the use of this signature on all electronic submission of dental insurance claims.

Medical History

Do you have or ever had any of the following? Please check off those that apply to you.

AIDS/HIV
Arthritis
Artificial joints
Anxiety
Angina
Asthma
Blood disorder
Breathing Problems
Cancer
Diabetes
Depression
Epilepsy
Fainting
Heart Disease
Heart Murmur
High Blood Pressure
Hepatitis
Hospitalization
Jaundice
Kidney Disease
Latex Allergy
Liver Disease
Mitral Valve Prolapse
Pacemaker
Stomach problems
Radiation Txt
Rheumatic Fever
Sinus Problems
Stroke
Ulcers
Smoking
Surgery
Thyroid Problems
Tumours
Pregnant, due on:
Are you under the care of a physician?
Yes No
Reason:
Are you taking any medications, drugs, supplements, herbs?
Yes No
Please List:
Are you allergic to any medications?
Yes No
Please List:
Other health concerns your dentist should know about:

Dental History

Former Dentist:
City:
Province:
Last Dental Visit:
Last Dental X-rays:

Do you have or ever had any of the following? Please check off those that apply to you

Bad Breath
Bleeding gums
Braces
Clicking Jaw
Dentures
Dry Mouth
Grinding teeth
Gum Surgery
Injury to Jaws
Headaches
Mouth Breathing
Mouth Sores
Tendency to faint
Food trap in teeth
Reaction to Freezing/Local Anesthetic
Sensitivity to:
Hot
Cold
Sweets
Chewing
Other conditions:
Reason for today’s visit:
Have you ever been advised to take antibiotics before dental appointments?
How often do you -
Have you been seeing a dentist regularly?
Yes No
How do you feel about your smile?
If given a choice, what would you like to change about your smile?

Informed Consent to Dental Treatment

*
I,      have read and answered the questions to the best of my knowledge.
*
I have discussed with the dentist, the risks, benefits and alternative options for my dental treatment including consequences of no treatment. I hereby authorize Dr. Rina M. Kotecha to perform any and all forms of dental treatment, medication and therapy indicated to treat my oral conditions.
*Patient/Parent or Guardian Signature
Date