PATIENT REGISTRATION FORM

Patient Registration, Health History & Office Policies

Address:280 Guelph Street, Georgetown, ON, L7G 4B1
Phone Number: 905-877-2273

Welcome to Marketplace Dental Centre

In order to provide you with optimum dental care we require a thorough medical and dental history, which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.

Personal Information

Patient's Name*

Patient's E-mail*

D.O.B*

Street Address, House number etc*

Landmark, Floor, c/o

City*

Country*

State/Province*

Zip/Postal Code*

+ 4

Tel. Home

Tel. Cell

Tel. Work

Name of Spouse

D.O.B.

Whom may we thank for referring you to our office?

Medical History (Confidential)

Physician's Name*

Physician's Phone #*

Date of Last Visit

Reason

Date of Last Physical

Name of Medical Specialist

Area of Specialty

Phone #

Indicate which of the following conditions apply to you presently or in the past.

Are you in good health?*

Yes No

Have you ever had a serious illness, operation, or hospitalization?*

Yes No

Are you now taking any medicine, drugs, or pills?*

Yes No

Do you have any blood disorders or do you bleed excessively?*

Yes No

Do you have a tendency to faint?*

Yes No

Are you on a special diet?*

Yes No

Do you have a prosthetic implant? (i.e. hip?)*

Yes No

Do you suffer from Diabetes?*

Yes No

Do you take blood thinners?*

Yes No

Do you smoke?*

Yes No

Are you now under the care of a physician for any ongoing treatment or therapy?*

Yes No

Do you have any allergies?*

Yes No

Have you ever had injury, surgery, or x-ray therapy to face or jaws?*

Yes No

Do you have frequent severe headaches?*

Yes No

Rheumatic or Scarlet Fever?*

Yes No

Do you have high blood pressure?*

Yes No

Do you bleed excessively?*

Yes No

WOMEN ONLY - Are you pregnant?*

Yes No

If you answered yes to taking any medicine, drugs, or pills, please list them here.

If you answered yes to having ANY allergies, please list them here.

If you answered yes to being under the care of a physician, please explain.

Dental History

What concerns you most about your dental health?

Date of last dental visit?

Date of last dental cleaning?

Date of last full mouth series of X-rays?

Do you see a dentist on a routine basis?*

Yes No

Have you ever had Orthodontic treatment (Braces)?*

Yes No

Have you ever had Periodontal treatment (Gum Surgery)?*

Yes No

Have you noticed any loosening of your teeth?*

Yes No

Do you suffer from pain and/or swelling of your gums?*

Yes No

Have you ever experienced clicking of the jaw?*

Yes No

Have you ever experienced difficulty in opening or closing?*

Yes No

Do you: Clench or grind your teeth while awake or asleep?*

Yes No

Do you: Hold foreign objects with your teeth (such as pencils, pipe, pins, nails, fingernails)?*

Yes No

Do you feel nervous about having dental treatment?*

Yes No

Is it important to keep your teeth?*

Yes No

Are you having pain at this time?*

Yes No

Have you ever had Oral Surgery?*

Yes No

Have you ever worn a bite guard or other appliance?*

Yes No

Does food tend to become caught between your teeth?*

Yes No

Do your gums often bleed when you brush your teeth?*

Yes No

Have you ever experienced pain (joint, ear, side of face)?*

Yes No

Have you ever experienced difficulty in chewing?*

Yes No

Do you: Bite your lips or cheeks regularly?*

Yes No

Do you: Mouth breathe while awake or asleep?*

Yes No

Have you ever had an upsetting experience in a dental office?*

Yes No

Are you dissatisfied with the appearance of your teeth?*

Yes No

If you could, what features of your smile would you like to change?

Is there anything else about having dental treatment that bothers you?

General Consent Statement: I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge, and have not knowingly omitted any information. I authorize the dentist to perform necessary diagnostic procedures and treatments to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive.*

I have read and agree to the above release.

Office Policies

In an effort to ensure your appointments are as pleasant and predictable as possible, we would like to give you an overview of our office policies. Please feel free to call us with any questions you may have.

About Insurance Billing
Due to the Canadian Personal Privacy Act, we are unable to access any sufficient information from your insurance company regarding your dental plan. It is your responsibility to know the details involved in your plan such as annual maximums, frequencies, and any other limitations.

In the event that your insurance provider does not pay the expected amount for whatever reason, you are responsible to pay your account in full. All accounts will be subject to a late fee of 2% per month, 30 days after a statement of account has been issued.

Your Appointment Reminders
Please understand that it is your responsibility to keep track of your appointments. We do everything we can to remind you of them in adequate time for you to make arrangements or changes for that appointment. As a courtesy, we will call you one week prior to a booked appointment and try to make confirmation calls one day prior to your appointment. Unfortunately, that is all we are able to do in order to remind you of the upcoming appointments, after that it is up to you to remember.

Our Cancellation Policy
Should you require to cancel or change an appointment please provide us with 24 hours notice to avoid a $100 fee that our dental office may charge to you.

Our desire is for you to have a pleasant experience in our office. We strive to serve you to the best of our ability in helping you attain maximum dental health.

I confirm that*

I have read and understood the above policies.

Patient/Parent/Guardian Signature:

Clear Signature

Submit

PATIENT REGISTRATION FORM

Patient Registration, Health History & Office Policies

Address:280 Guelph Street, Georgetown, ON, L7G 4B1 Phone Number: 905-877-2273

Welcome to Marketplace Dental Centre

Address:280 Guelph Street, Georgetown, ON, L7G 4B1
Phone Number: 905-877-2273