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1553 Hurontario St., Mississauga, ON L5G 3H7 | Directions
Call: (905) 455-9262

New Patient Registration and Medical History Form

Welcome to Dentistry on 10 where we strive to provide you with a healthy and happy smile. Please fill out this survey accurately and completely in order for us to provide you with the best possible dental care.

Personal Information :

Patient Name :
*Last Name
Middle Name *First Name
*Date of Birth :
*Home Address :
Postal Code
*Home Phone # : () - -
Cell Phone # : () - -
*Email :
Marital Status: Single Married Divorced Widowed Other
Employer : Phone # : () - -
Employer Address : City :
State : Postal Code :
Family Physician : Phone # : () - -
Date of Last Medical Exam :
Spouse, Parent, or Guardian Details
Name of Spouse, Parent, or Guardian :
Employer :
Employer Address : City :
State : Postal Code :
Home Phone # : () - -
Phone (Bus) # : () - -
Emergency Contact Details
Contact Name : Phone # : () - -
Whom may we thank for referring you to our practice? Another Patient
Web page Newspaper Flyer Yellow Pages Other

Insurance Information :

Primary Insurance Information
Do you have dental insurance? Yes No
Name of Insured :
Relation to Insured : Date of Birth :
Insurance Company :
Group Number : ID Number :
Credit Card Type : Number :
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 Number : ID Number :
* 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 Brush? Floss?
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