New Patient Medical Form Patient Information: Province/Territory Choose an option BC AB SK MB ON QC NS NB PEI NL YT NT NU Referring Dentist Information: Emergency Contact Information: Medical Information: The following information is required so that we may provide you with the best possible care. The doctor will review all of the questions. Please fill out the entire form. If you need further clarification of any of the questions, please ask a team member or the doctor.
1. Are you currently being treated for any medical condition now or within the past year?
2. Describe any current medical treatment, upcoming surgery or upcoming treatment that may affect your dental treatment.
3. Do you have or have you ever had any of the following conditions?
4. List any medications, supplements or vitamins taken within the last 2 years. (Drug & Purpose)
5. Do you have any allergies that result in rash, hives or swelling (ie; to medications, latex products, etc.)?
6. Have you ever had an adverse reaction (nausea, dizziness) to any medications or injections?
7. Do you have or have you ever had asthma?
Did you bring your inhaler with you today?
8. Do you have an artificial or prosthetic joint/heart valve?
9. Do you have any conditions or have you had any therapy that could affect your immune system?
10. Have you ever had hepatitis, jaundice or liver disease?
11. Do you have a bleeding problem/disorder?
12. Have you ever been hospitalized for any illness or operations?
13. Do you smoke or chew tobacco products?
14. Are you anxious/nervous during dental treatment?
Have you been prescribed medication in thepast to help you relax during dental appointments?
15. For Women: Are you pregnant or breast-feeding?
16. Are there any other conditions not listed that you have had?
I confirm that the above information is correct, to the best of my knowledge. Further, I consent to the collection, use or disclosure of my or my dependents (“the patient”) personal information as it is required for my own and/or dependents dental care. I also consent to receiving emails regarding my treatment. Dental Insurance Information: Please note that the complete cost of the dental visit will be due on the date of service by Visa, MasterCard, or Debit. We do not accept personal cheques or cash. We can assist you by sending your insurance forms to your insurance company on your behalf. Your insurance company will reimburse you directly for the coverage you have with them. I understand that I am fully responsible for the prompt and full payment of my account. I also authorize the release of financial information to my dental plan benefits plan administrator and the Canadian Dental Association in order to facilitate the submission of my electronic dental claims submission by this office on my behalf. Submit Form Thank you for sending your form to us at Westside. Your form has been submitted!