Patient Information Form

Patient’s Name:

Date of Birth:

Address:

Home Phone:

Business Phone:

E-Mail Address:

Business Address:

Occupation:

Name of spouse, parent or nearest relative:

Employer:

Business Phone of Employer:

Referring Dentist:

Family Physician:

Do you require an insurance form?:

(If yes, provide name of insurance company):

Health History

Are you in good health? Yes No

Have you been treated by a physician during the past 5 years  Yes No

Are you sensitive or allergic to Novacaine, Penicillin, Codeine, Aspirin or any other medication? Yes No

If yes please state which ones

Are you taking any medication? Yes No

If yes please state which ones

Have you ever had an unfavourable reaction following dental treatment?  Yes No

Have you ever had excessive bleeding requiring special treatment?  Yes No

Have you ever had any of the following illnesses:
 Stroke Heart Murmur Mitral Valve Prolapse (MVP)  Artificial Body Parts High Blood Pressure Rheumatic Fever  Dizziness Asthma Hepatitis A Hepatitis B Hepatitis C HIV+ Jaundice Tuberculosis Diabetes Venereal Disease AIDS Kidney Disease Epilepsy Nervous Disorders

Have you had any serious illness? Yes No

Have you ever had root canal treatment? Yes No

Female patients: are you pregnant? Yes No

If so which month?

I, the undersigned, being the patient, parent or guardian of the above minor patient, consent to the performing of whatever procedure may be determined necessary or advisable, in the opinion of the Doctor. A report of treatment will be sent to my referring dentist. I also understand that upon completion of root canal therapy in this office I will be referred to my general dentist for permanent restoration such as crown, cap, jacket, onlay or filling.
I understand that the total payment of the dental service is my responsibility and not that of the insurance company. Payment is due when services are rendered.

Patient Name:

Authorization/Electronic Confirmation (please type your name again):