Countryhillsdentistry.ca

Date month/day/year ______/______/_______ In order to provide you with the highest standard of dental care, please provide our dental office with the fol owing Personal Information and Medical and Dental Histories. The protection and privacy of your personal information is important to our office and we are committed to col ecting, using, disclosing this information responsibly. Please complete this form by neatly printing.
ADULT PATIENT REGISTRATION INFORMATION
Dr.  Mr.  Mrs.  Miss  Ms  Other:___________
Name: (Last, First, Ini)

In the future, please circle how we may contact you to confirm your appointments: Email or Telephone ( home or mobile )
Employer Name:
Spouse’s Employer Phone Number: Is another family member a patient here at our office? Yes  or No  CHILD PATIENT REGISTRATION INFORMATION

Name: (Last, First, Ini)
Address: (if different from above) Home Phone: (if different from above) Is another family member a patient here at our office? Yes  or No 
MEDICATIONS: LIST ALL PRESCRIPTION, NON-PRESCRIPTION, HERBAL MEDICATIONS THAT YOU ARE TAKING-- INCLUDE NAME, DOSE AND FREQUENCY.
(**IF THE LIST IS LENGTHY PLEASE GIVE LIST TO RECEPTIONIST TO PHOTO COPY**)


INSURANCE INFORMATION
Single Coverage
Double Coverage

MEDICAL INFORMATION (circle one)
Have you ever had extensive medical care? Yes  or No 
Are you presently under the care of a physician? Yes  or No  Have you been hospitalized in the last 5 years? Yes  or No  Have you had a medical examination in the last year? Yes  or No  Do you have any allergies to any medication? Yes  or No 
Do you have any al ergic conditions? (i.e. latex, metal, food allergies) ? Yes  or No 
Have you ever been advised not to take a certain drug or medication? Yes  or No 
Has your Doctor ever told you to take antibiotics prior to a dental procedure? Yes  or No  If yes, when?

Please circle if you have a history of any of the fol owing:

Please circle either Yes or No to each question:
Have you ever had any known contact with the AIDS
Has any member of your family had diabetes? Have you had any weight changes lately? Do you have any blood disorders such as anemia Have you ever had radiation treatment or Have you ever had an injury, surgery or x-ray Do you have frequent earaches, ear/throat Do you ever experience shortness of breath or chest pain when walking or climbing stairs? Have you had any organ transplants or medical Do you have any disease, condition or problem that you think the doctor should know about? Y N Describe Is there anything about yourself that we Have you ever been diagnosed or treated for Have you ever taken any of these medications FEMALE PATIENT INFORMATION (Adult)
Have you ever been diagnosed or treated for If you answered Yes to any of the above questions, please provide the fol owing information: Name and phone number of your Primary Physician Name and phone number of your Specialist
MALE PATIENT INFORMATION (Adult)
Have you ever been diagnosed or treated for
If you answered Yes to any of the above questions, please provide the fol owing information: Name and phone number of your Primary Physician Name and phone number of your Specialist DENTAL HISTORY

Is there a dental problem you would like to
Have you been given oral hygiene instruction How often do you floss? Other cleaning aids used: Are any of your teeth sensitive to: Cold Have you ever had or do you now have any of the fol owing? (please circle) Bridges Do you chew on only one side of your mouth? Have you experienced any growths or sore Do you grind or clench your teeth during the Do you mouth breathe while awake or asleep? Do you bite your lips or cheeks regularly? Do you hold any foreign objects with your
Circle any of the fol owing that you are interested in:
Orthodontics

How did you find out about our office? (circle one)
Person’s Name

**We would greatly appreciate a notice of at least 2 full business days if you need to make changes to your appointments.**

Source: http://countryhillsdentistry.ca/sites/default/files/forms/DENTAL%20OFFICE%20FORM.pdf