New Patient Form

First Name

Middle Name

Last Name

Gender

Date of Birth

Cellphone

Home Phone

Work Phone

Address

Occupation

Employer

Employer Addres

Family Information And Emergency Contact

Option 1

Full Name

Relation to Patient

Phone Number

Date of Birth

Employer

Address

Emergency Contact if Different from Above

Option 1

Full Name

Relation to Patient

Phone Number

Date of Birth

Address

Insurance Information

Option 1

Insurance Information

Policy Holder

Policy Holder’s Date of Birth

Policy Holder’s ID #

Group #

Insurance Company Address

Insurance Company Phone

Insurance Company Fax

Secondary Insurance Company

Policy Holder

Policy Holder’s Date of Birth

Policy Holder’s ID #

Group #

Insurance Company Address

Insurance Company Phone

Insurance Company Fax

Payment is Due at the Time of Service

Date

Initial

Dental History

Are you having discomfort at this time?

What is the discomfort?

How long since you have been to a dentist?

Did you have X-Rays?

What else was done?

Are your teeth sensitive to:

Have you ever had your teeth straightened?

When?

Did you have traditional braces?

How often do you brush your teeth?

How often do you use dental floss?

Do you have bleeding gums?

Have you ever had gum treatment?

When?

Do you grind or clench your teeth?

Do you hear popping clicking noises when you chew?

Do you have any pain around either of your ears?

Any swelling or lumps in your mouth?

Do you have any fear of dental treatment?

How do you feel about the appearance of your teeth.

Are antibiotics necessary prior to treatment?

Medical History

Physician’s Address

Physician’s Phone

Physician’s Name

Please list any serious medical condition(s) that you have experienced

List of Medications

Please list additional drugs/materials that cause allergic reactions

For Women

Are you pregnant?

Week #:

Are you nursing?

Authorization

Notice of Privacy Practices Summary

Print Patient Name

Date

Get In Touch

Phone:

(416) 544-0707

(416) 544-9191

Email:

info@doredentalclinic.ca

Address:

2042 Avenue Rd, North York, M5M 4A6

New Patient Form

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