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Mount Royal Dental

Patient Registration Information

MR. MRS. MISS. MS. MSTR. DR.

  Last name

  Mid name

  First name
    
    
Gender: Male Female
Single Married Partnered Divorced/Separated Widowed
City
Prov.
Postal
APT#
Home phone #:*
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Cell #:
()- -
Work phone #:
()- - -
Home Work Cell Email

Employer Details-
Emergency Contact Details-
Contact Phone #:
()- -
Medical Doctor's Details-
Contact Phone #:
()- -
Responsible Party for Account-
Yes No
**Please give you information to the receptionist prior to your appointment.

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

1. Have you ever been to hospital for any illnesses, operations, trauma/accidents, check-ups/tests? Yes No
If Yes, Please Explain:
2. Have you had a medical examination in the last year? Yes No
3. Are you currently under the care of a physician for any problem? Yes No
If Yes, Please Explain:
4. Are you presently taking any medicine, non-prescription drugs or herbal supplements? Yes No
If Yes, What and Why?:
5. Do you have, or have you ever had, any of the following?
Rhuematic Fever
Thyroid Disease
Kidney Disease
Lung Disease
Heart Trouble
High Blood Pressure
Diabetes
Asthma
Heart Murmur
Venereal Disease
Liver Disease (Jaundice, Hepatitis)
Epilepsy
Joint Replacement
Gastrointestinal Disease
AIDS
Cancer
Mental or Nervous Disease
Blood Disorders
Sinusitis
Anemia
Radiation or X-ray Therapy
Chest pain, Angina
Stroke
Shortness of Breath
Pacemaker
Steroid Therapy
Stomach Ulcers
Dialysis
Drug/Alcohol Dependency
Osteoporosis Medications (eg. Fosamax, Actonel)
6. Do you have any conditions or therapies that could affect your immune system?
(eg. Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Yes No
7. Do you have any allergies? If Yes, Please list using the categories below? Yes No
8. Have you ever had a peculiar or adverse reaction to any medications? Yes No
If Yes, Please Explain:
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (ie: infective endocarditis), a heart condition from birth (ie: congenital heart disease) or a heart transplant? Yes No
10. Do you have a bleeding problem or bleeding disorder? Yes No
11. Have you ever fainted? Yes No
If Yes, When?
12. Are there any disease or medical problems that run in your family?(eg: diabetes, cancer, heart disease) Yes No
If Yes, Please Explain:
13. Do you smoke or chew tobacco products? Yes No
How Much?
14. Are you aware of snoring? Yes No
15. Have you been diagnosed with sleep apnea? Yes No
Do you use a CPAP machine? Yes No
16. Is there anything that the dentist should know about your general health that has not been mentioned? Yes No
If Yes, Please Explain:
17. To the best of your knowledge, are you in good health? Yes No
WOMEN- Are you pregnant/breastfeeding? Yes No
Are you on birth control pills? Yes No

Dental History

1. Last dental visit:
Reason: 
2. Last X-rays:
Reason: 
3. Are you aware of bad breath or a bad taste in your mouth? Yes No
4. Are you aware of grinding/clenching your teeth? Yes No
If Yes, Do you wear a night guard?  Yes No
5. Do you have a history of jaw/TMJ problems? Yes No
6. Do you chew gum every day? Yes No
7. Have you ever had freezing (local anaesthetic) in your mouth? Yes No
Any ill effects from it?  Yes No
8. Have you ever had a bad experience at the dentist? Yes No
9. What, if any, is your current dental problem?
10. Are you nervous in the dental office? (Scale of 1 - 10, with 10 being Very Nervous)
1 2 3 4 5 6 7 8 9 10

Office Policy

Please help us maintain the operation of our office on sound principles so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you. Therefore, 2 business days NOTICE must be given if cancellation is absolutely necessary.
Office policy is that services are paid for at each visit as they are performed. However, in certain circumstances, arrangements for payment may be made by consulting the doctor prior to treatment.
Regarding insurance: All professional services are charged directly to the patient and patients are personally responsible for payment of bills on their accounts. We will prepare any necessary forms or reports to help you collect your benefits from your insurance company.

*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)