Baseline Dental Centre | New Patient Form

NEW PATIENT FORM

We understand that your time is valuable and in order to streamline your first visit, simply complete at your convenience, prior to your appointment. If you would rather complete the forms at our office, we ask that you kindly arrive 15 minutes before your scheduled appointment. You will enjoy a complimentary beverage, and feel free to ask for our assistance with any questions you might have.

Are you a new or existing patient?

New
Existing

REFERRAL INFORMATION

How did you hear about our clinic? *

How did you hear about our clinic (other)

Other

PATIENT INFORMATION

Patient Type

Adult
Child
Adult Under Guardianship

Gender

Male
Female
Other

Name *

First

Last

Date of Birth//

Address

Address Line 1

City

Province

Code Postal

Email *

Phone Number - Home

Phone Number - Cell

Phone Number - Work

Marital Status

Single
Married
Common Law

Employer - Name

Family Physician - Name

Specialist - Name

Emergency Contact Phone Number

INSURANCE INFORMATION

Insurance Company Holder

Self
Spouse
Parent/Guardian

Insurance Company Name

Name of Insurance Policy Holder

Policy Holder Date of Birth//

Group Policy/Plan Number

ID/Certificate Number

FINANCIAL INFORMATION

Person responsible for account

Self
Spouse
Parent
Other

Name of person responsible for account

First

Last

Preferred Method of Payment

Interac
Visa
Cash
Mastercard

DENTAL INFORMATION

Date of your last dental exam//

Date of your last dental cleaning//

Date of your last dental xrays//

Please check any of the following problems that may apply to you.

Sensitivity (hot, cold and/or sweet)
Tooth pain or discomfort while chewing
Headaches, earaches or neck pain
Jaw joint pain (clicking/cracking)
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, chipped or shifting teeth
Bad breath or bad taste in your mouth

Do you have, or have you had any of the following?

Dentures
Orthodontics
Partial dentures
Periodontal (gum) treatments

If you could change your smile, you would….

How important is your dental health to you?

On a scale of 1 to 10, with 10 being the highest rating

Where would you rate your current dental health?

On a scale of 1 to 10, with 10 being the highest rating

Are you leaving your previous Dentist?

Yes
No

Leaving a previous Dentist explanation

Please explain why you are leaving your previous dentist

What, if anything, in the past has kept you from having dental treatment?

What is the most important thing about your future smile and dental health?

What is most important thing to you about your upcoming visit?

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year?

Yes
No

Medical condition or treatment explanation

Please explain your medical condition or treatment

When was your last medical checkup?//

Has there been any change in your general health in the past year?

Yes
No

General health changes

Please explain the change(s) in your general health

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

Yes
No

Medications, non-prescription drugs or herbal supplements explanation

Please list any medications, non-prescription drugs or herbal supplements you are taking

Do you have any allergies?

Yes
No

Allergies - explanation

Please list any allergies you have

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes
No

Adverse reaction to any medicines or injections - explanation

Please explain the peculiar or adverse reaction you had

Do you have or have you ever had asthma?

Yes
No

Do you have or have you ever had any heart or blood pressure problems?

Yes
No

Heart or blood pressure problems - explanation

Please explain your heart or blood pressure problem

Do you have or have you ever had: a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?

Yes
No

Replacement or repair of a heart valve, an infection of the heart, a heart condition from birth, or a heart transplant - explanation

Please list which of these you have have or had

Do you have a prosthetic and/or artificial joint?

Yes
No

Prosthetic or artificial joint - explanation

Please list which prosthetic and/or artificial joint you have?

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?

Yes
No

Conditions or therapies that could affect your immune system - explanation

Please list any conditions or therapies that could affect your immune system

Have you ever had hepatitis, jaundice or liver disease?

Yes
No

Hepatitis, jaundice, or liver disease - explanation

Please list which of these conditions you have or had

Have you ever been hospitalized for any illnesses or operations?

Yes
No

Hepatitis, jaundice, or liver disease - explanation (copy)

Please list which illnesses and/or operations you were hospitalized for

Do you have or have you ever had any of the following? Please check all that apply.

Are there any conditions or diseases not listed above that you have or have had?

Yes
No

Conditions or diseases not listed - explanation

Please list which conditions or diseases that you have or had

Do you smoke or use other nicotine products?

Yes
No

Are you breastfeeding or pregnant?

Yes
No

Do you identify as a patient with a disability?

Yes
No

GENERAL RELEASE

I agree to your cancellation policy and understand that two (2) business days notice is required to reschedule my appointment.

I agree
I do not agree

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario

Date of Agreement//

(613) 224-2332

1883 Baseline Rd.

Monday & Wednesday 8 A.M. - 5 P.M.

Tuesday & Thursday 8 A.M. - 8 P.M.

Friday 8 A.M. - 4 P.M.

New Patient Form