Patient Registration Form Patient Information - All fields requiredName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth:* Registering for a child?YesNoPerson responsible for account:Second parent consent required?YesNoMother’s Name:Business Telephone:Father’s Name:Business Telephone:Contact Information (for both parents)Email: Home Phone:Cell Phone:Work Phone:Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact (alternate to parents)- In case of emergency, please notify: Name:Relation:Home Phone:Cell Phone:Work Phone:Email Contact OptionsI prefer appointment reminders by:PhoneSMS(TEXT)EMAILEmail:Whom may we thank for referring you?Are any other members of your family patients at our practice:YesNoPlease list all family members:Insurance InformationYes, insurance applies to meNo, insurance does not apply to mePlease complete the following if you have dental insurance:Name of insured/subscriber:Date of birth: Patient’s relationship to subscriber:SelfSpouseChildPlace of Employment:Insurance Company:Policy/Group #:Certificate/ID #:I authorize release of my dental records to my dental benefits plan administrator as well as information contained in claims and/or predeterminationsYesNoMedical 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 complete the entire form.Are you being treated for any medical condition at the present or any time within the past year?YesNoNot Sure/MaybePlease list and provide all medication names and dosages. If there is insufficient room, please bring a written list of all medications, prescriptions, non-prescription or any herbal supplements along with dosages to your first appointment.Do you have any allergies?YesNoNot Sure/MaybeHave you ever had a peculiar or adverse reaction to any medicines or injections?YesNoNot Sure/MaybePlease list below with approximate dates:Do you have or have you ever had asthma?YesNoNot Sure/MaybeDo you have or have you ever had any heart or blood pressure problems?YesNoNot Sure/MaybeDo you have or have you ever had an artificial heart valve, infection of the heart (ex: infective endocarditis), a heart condition from birth (ex: congenital heart disease), or a heart transplant?YesNoNot Sure/MaybeDo you have a prosthetic or artificial joint?YesNoNot Sure/MaybeDo you have any conditions which may affect your immune system (ex: lieukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?YesNoNot Sure/MaybePlease specify:Have you ever had hepatitis, jaundice, or liver disease?YesNoNot Sure/MaybeDo you have a bleeding problem or bleeding disorder?YesNoNot Sure/MaybePlease specify:Are you taking blood thinners?YesNoPlease specify:Are you taking Aspirin?YesNoPlease specify dosage and frequency:Do you have, or have ever had any of the following? Please check: Select All Chest Pain/Angina Osteoporosis medications Mitral Valve Prolapse Shortness of Breath Rheumatic Fever Heart Attack Stroke Cancer Pacemaker Lung Disease Heart Murmur Arthritis Steroid Therapy Diabetes Tuberculosis Drug/alcohol Dependency Seizures Thyroid Disease Stomach Ulcers Kidney Disease None of the above Are there any conditions/diseases not listed that you have or have had?YesNoNot Sure/MaybeIf yes, please specify:Are you nervous during dental treatments?YesNoNot Sure/MaybeFor women only: Are you pregnant or breastfeeding?YesNoNot Sure/MaybeWhat is your expected delivery date? Dental History Do you have any specific dental concerns? Please list:In the past, how often did you see the dentist?Not ApplicableEvery 3 monthsEvery 4 monthsEvery 6 monthsOnly when something was bothering me This iframe contains the logic required to handle Ajax powered Gravity Forms.