Patient Intake Form Step 1 of 7 14% New Patient InformationFirst Name(Required) Last Name(Required) Birth Date MM slash DD slash YYYY Email(Required) Main Phone(Required)Cell Phone (If different than main) Patient AddressAddress(Required) City(Required) Province(Required)ProvinceAlbertaBritish ColumbiaSaskatchewanManitobaOntarioQuebecNewfoundlandNew BrunswickNova ScotiaPEINWTNunavutYukonPostal Code(Required) Emergency Contact DetailsParent or Guardian Name (If Applicable) Emergency Contact Name Emergency Contact Number Patient Dental HistoryPrevious Dentist Previous Clinic Phone NumberDate of Last Exam MM slash DD slash YYYY Date of Last Cleaning MM slash DD slash YYYY Date of Last X-rays MM slash DD slash YYYY Do you feel any pain in your teeth?(Required) Yes No Do your gums bleed while brushing/flossing?(Required) Yes No Do you have any sores or lumps in/near your mouth?(Required) Yes No Do you favor one side of your mouth when you eat?(Required) Yes No Have your gums ever been swollen or tender?(Required) Yes No Do you have a hyperactive gag reflex?(Required) Yes No Have you ever had any unusual reaction to fluoride or freezing?(Required) Yes No Have you had any of the following habits? Clench or Grind Teeth Mouth Breath Bite Your Nails Snore Have you ever had any head, neck, or jaw injuries?(Required) Yes No Please provide details here...(Required)Do you have frequent head, neck or shoulder aches?(Required) Yes No Please provide details here...(Required)Have you ever experienced any of the following problems in your jaw? Clicking Pain Difficulty Opening/Closing Difficulty Chewing Have you ever had any of the following dental treatment? Filling Extractions Root Canal Treatment Crown or Bridge Orthodontic Treatment Patient Medical HistoryYour Doctor Your Medical Clinic Doctor's Phone NumberAre you taking any medication(s) including non-prescription medicine?(Required) Yes No what medication(s) are you taking? Please provide a complete list of medication?Do you have any allergies?(Required) Yes No please provide details.Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?(Required) Yes No please provide details.Do you smoke? Yes No Do you wear contact lenses? Yes No Have you ever had any of the following? (Please check all the applicable boxes) AIDS or HIV Infection Anemia Angina Mental Disorder Nervous Disorder Arthritis Asthma/COPD Bleeding Problems Cancer Cardiac Pacemaker Cleft Lip or Palate Chest Pains Cirrhosis Cystic Fibrosis Diabetes Eating Disorder Emphysema Epilepsy/Convulsions Fainting/Seizures Fibromyalgia Glaucoma Heart Attack Heart Disease Heart Murmur Heart Surgery or Transplant Hepatitis High Blood Pressure Low Blood Pressure Joint Replacement Kidney Disease Leukemia Liver Disease Osteoporosis/Osteopenia Radiation/Chemo Therapy Respiratory Problems STD Sinus Trouble Stomach Troubles/Ulcers Stroke Thyroid Disease Women OnlyAre you pregnant or think you may be pregnant? Yes No Are you nursing? Yes No Are you taking oral contraceptives? Yes No Do you have allergies? Yes No please provide details. Authorization & Agreement DetailsAuthorization and Release of Information(Required)I (patient, parent or guardian) certify that I have read and understand the above information to the best of my knowledge and that the dental and medical profiles I have provided are complete and accurate. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such dental care to third party payers and or health practitioners for the purpose of administering claims. I authorize the release of information contained in claims to be submitted electronically to my insuring company plans administrator. I accept Payment Authorization(Required)I (patient, parent or guardian) authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to the patient. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for the payments of all services rendered on my behalf or dependents. I authorize Fort McMurray Dental to immediately process any outstanding balance under $200.00 towards the credit card as indicated below. Any outstanding balances owing that are over $200.00 will be processing in monthly increments of $200.00 until balance is fully paid. I am aware I will be contacted regarding my outstanding balance and any payment not processed within 90 days, unless otherwise discussed with management, will be deemed uncollectable and forwarded to a collection agency. I accept Cancellation Policy(Required)I agree and am aware of the $50.00 fee if I fail to show to my dental appointment or need to cancel or reschedule an appointment within less than 2 business days. I accept Signature of ApprovalPrint Patient/Guardian Name Signature(Required)Date
