Patient Information

Name: *

Sex:

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Preferred Name

First Preferred Pronouns

D.O.B(Mm/Dd/Yyyy) *

Address *

City *

Zip code *

Contact Number: *

Alt Number:

Email *

How Did You Hear About Us?

Family Doctor / Emergency Contact

Family Physician:

Office Number:

Are You Seeing A Specialist? If Yes, Explain:

Emergency Contact Name: *

Contact Number: *

Relationship: *

Dental Insurance (Primary Coverage)

Employer:

Plan Holder’s Name:

Insurance Company:

Group/Policy Number:

Member ID Or Certificate Number:

Dental Insurance (Secondary Coverage)

Employer:

Plan Holder’s Name:

Insurance Company:

Group/Policy Number:

Member ID Or Certificate Number:

Medical History

When Was Your Last Dental Cleaning And Check-Up?

Has There Been Any Change In Your General Health In The Past Year? If Yes, Please Explain.

When Was Your Last Medical Check Up?

Please list the medications you are currently taking: (Non-prescription drugs or herbal supplements included)

Medication 1

Reason 1

Medication 2

Reason 2

Medication 3

Reason 3

Medication 4

Reason 4

Medication 5

Reason 5

Medication 6

Reason 6

Medication 7

Reason 7

Reason 8

Medication 8

Do You Have Any Allergies? *

Do You Have Or Have Ever Had Asthma? *

Heart And/Or Blood Pressure Problems? *

Do You Have, Or Have You Ever Had A Heart Murmur, Mitral Valve Prolapse, Or Rheumatic Fever? *

Do You Have A Prosthetic Or Artificial Joint? *

Have You Ever Been Advised By Your Doctor To Take Antibiotics Before Dental Treatments? *

Do You Have Any Conditions That Could Affect Your Immune System? (Example, Leukemia, AIDS, HIV Infection, Radiotherapy, Chemotherapy) *

Have You Ever Had Hepatitis, Jaundice, Or Liver Disease? *

Do You Have A Bleeding Problem Or A Blood Disorder? *

Have You Been Hospitalized For Any Illnesses Or Operations In The Last 2 Years? *

Do you have, or have ever had any of the following? Please check

Stroke

Heart attack

Chest pain/Angina

Pacemaker

Lung disease

Thyroid disease

Steroid therapy

Diabetes

Seizures/Epilepsy

Prosthetic heart valve

Kidney disease

Physical conditions

Shortness of breath

Stomach ulcers

Drug/alcohol dependency

Cancer

Arthritis

Psychological conditions

If Yes To Any Above, Or Other Conditions That Are Not Listed, Please Explain:

Do You Smoke, Vape, Or Chew Tobacco? If So, How Often? *

Women Only: Are You Pregnant, Or Breastfeeding?

Personal Health Information Act

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the new collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance. Your personal health information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA.

Patient Consent

I have reviewed the above information that explains how my office will use my personal health information, and the steps your office is taking to protect my information. I agree that Parkside Drive Dental can collect, use and disclose my personal health information as set out above in the office’s privacy policies. To the best of my knowledge, the above information is correct:

Print Name: *

Date:

Signature: *

Clear

(Parent/Guardian if patient is under 18)