(613) 224-2332
booking@BaselineDentalCentre.com
1883 Baseline Rd.
Ottawa, Ontario K2C 0C7
Monday & Wednesday 8 A.M. - 5 P.M.
Tuesday & Thursday 8 A.M. - 8 P.M.
Friday 8 A.M. - 4 P.M.
Closed on Weekends
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COVID-19 Screening Questionnaire
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Update Medical History
Book an appointment
Baseline Dental Centre | New Patient Form
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New Patient Form
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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?
*
Social Media
Search Engine
Radio
Lives In Area
Works in Area
Friend/Family
Patient Referral
Employee Referral
Event
How did you hear about our clinic (other)
Other
PATIENT INFORMATION
Patient Type
Adult
Child
Adult Under Guardianship
Gender
Male
Female
Other
Name
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Last
Date of Birth
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Address
Address Line 1
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Ontario
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Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Saskatchewan
Yukon
Province
Code Postal
Email
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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
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Group Policy/Plan Number
ID/Certificate Number
FINANCIAL INFORMATION
Person responsible for account
Self
Spouse
Parent
Other
Name of person responsible for account
First
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Preferred Method of Payment
Interac
Visa
Cash
Mastercard
DENTAL INFORMATION
Date of your last dental exam
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Date of your last dental cleaning
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Date of your last dental xrays
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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….
Make your teeth brighter
Make your teeth straighter
Close gaps between teeth
Replace metal fillings with natural tooth coloured fillings
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Have a smile makeover
How important is your dental health to you?
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On a scale of 1 to 10, with 10 being the highest rating
Where would you rate your current dental health?
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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?
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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.
Arthritis
Cancer
Chest Pain, Angina
Diabetes
Drug/Alcohol/Cannabis use or dependency
Heart Attack
Heart Murmur
Kidney Disease
Lung Disease
Mitral Valve Prolapse
Osteoporosis medications (e.g. Fosamax, Actonel)
Pacemaker
Rheumatic Fever
Shortness of Breath
Steroid Therapy
Stomach Ulcers
Stroke, TIA
Thyroid Disease
Tuberculosis
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
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