Complimentary Consultation

Patient Information Form

Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
 

Patient Name:

First
Middle
Last
 
Preferred Name

Title:
Gender:
Status:
Birth Date: ( DD/MM/YY )
E-mail Address:
 
Phone:
Home:
Work:
Mobile:
 
Best time to call:
Address:
 
City
Province
Postal Code

Occupation:
Employer:
Family Doctor:
 
Doctor Phone:
Emergency Contact:
Relationship to patient:
 
Emergency Phone
 
Who is responsible for this account?:
Relationship to patient:
 

Dental History:

Reason for this visit:
When was your last dental visit?:
Name of your last dentist:
 
Do you have x-rays taken within last 12 months?

How often do you brush?:
How often do you floss?:
 
Do your gums ever bleed?:
Do you have loose or drifting teeth?:
Do you know if you grind your teeth?:
 
Does your jaw click, pop or hurt?:
Are you satisfied with the appearance of your teeth?
Have you had any complications
or difficulty with previous dental treatment?:
 

How do you rate yourself as a dental patient?

calm Slightly Nervous Very Anxious
 

Medical History :

Are you currently in good health? If no, please explain:
Are you under the regular care of a physician(s)?:
Have you ever had a serious illness or operation?:
If yes, please explain?

Whom may we thank for referring you to Apple Dental Group?
Name
Facebook Postcard
 
AppleDentalGroup.ca Newspaper Ad Drive by / Walk in
 
Other (name below):
   

Please indicate if you have experienced any of the following:
Allergy- Aspirin Allergy- Codeine Allergy- Erythromicin Allergy- Latex
Allergy- Local Anesth Allergy- Penicillin Allergy- Sulfa Anemia
Arthritis Artificial Joints Asthma Birth Control Pill
Blood Disease Cancer Diabetes Dizziness/ Fainting
Emphysema Epilepsy Excessive Bleeding Excessive Bruising
Gastro-Intestinal Concerns Glaucoma Hard to Freeze Hay Fever
Head Injury Hearing Disabled Heart Disease Heart Murmur
Hepatitis A Hepatitis B Hepatitis C HIV+ (AIDS)
High Blood Pressure Hives Jaundice Kidney Disease
Liver Disease Low Blood Pressure Mental Disorders Multiple Sclerosis
Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems
Reumatism Rheumatic Fever Rheumatoid Arthritis Sinus Problems
Skin Rash STD Stomach Problems Stroke
Sleep Apnea Snoring Thyroid Disease TMJ
Tobacco Use Tuberculosis
 
What medications and vitamins are you currently taking?
 
What Medications are you allergic to?
 
Do you require Pre-medication for dental treatment?
 
Do you smoke? If yes, how long have you been:
 
Have you had persistent cough for the last 24 hours?:
 
WOMEN ONLY:
Are you pregnant? Yes, when is the due date?

Insurance

Primary Policy Holder

Name of Primary Policy Holder

Birthdate of Primary Policy Holder

Name of Insurance Company

Policy/Plan/Group #      Certificate / ID #

 

Secondary Policy Holder

Name of Secondary Policy Holder

Birthdate of Secondary Policy Holder

Name of Insurance Company

Policy/Plan/Group #      Certificate / ID #


Agreement and Consent for Services:

Apple Dental Group depends on reimbursement from patients and/or their benefits for costs incurred in their care. Our office can file dental claims on your behalf, but are not a party to any insurance programs or contracts. Your dental benefits are a contract between yourself, your employer and your insurance provider. Per the Privacy Act, your plan details will not be released to us, as it is confidential medical information.

For dental services that I have consented to, I will assume responsibility for associated fees. I understand that financial responsibility on the part of each patient must be determined before treatment. An interest charge of 18% per annum will be charged on balances exceeding 90 days, unless previous written agreements are satisfied. I assume responsibility for all costs, should I have any delinquent balances forwarded to a third party collections agent.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

I acknowledge I will be required to provide a valid credit card on the date of my appointment

I have read the above conditions of treatment and payment and agree to their content

Date: ( DD/MM/YY )

        Other