Please fill out and submit the form below prior to your first visit. If you prefer to print and manually fill out a PDF version of this form please click here.

Welcome to our Dental Office

The personal information provided below will be protected and keep private by our office. All information will be used and disclosed responsibly according to the Privacy Act standards set up and monitored by our office.

Mr. Mrs. Miss. Ms. Dr.

Given Name

Surname

Marital status

Pronunciation

Prefer to be called

Address

Street

Apt#

City

Postal Code

Home Phone

Work Phone

Date of Birth

Fax

Other phone

Male Female Adult Child

Employer / School

Occupation

Email Address

Contact Method

Who may we thank for refering you to this office?

Are you likely to be available on short notice for future appointments? Yes No

Family Physician

Phone

In Case of Emergency Notify

Relation

Phone

Person responsible for this account? Self Spouse Parent Legal Guardian Other

Other

Last Name

First Name

Initial

Relation

Address

Street

Apt#

City

Postal Code

Home Phone

Work Phone

Driver licence number

Primary Insurance

Subscriber

Date of Birth

Relation Self Spouse Other

Other

Subscriber I.D.

SIN

Insurance Co

Policy/Plan #

Division/Sect. #

Are You Familiar with Your plan Details? Yes No

Secondary Insurance

Subscriber

Date of Birth

Relation Spouse Other

Other

Subscriber I.D.

SIN

Insurance Co

Policy/Plan #

Division/Sect. #

Are You Familiar with Your plan Details? Yes No

Method of Payment Cash Cheque Credit Card

Credit Card

Number

Exp.

MEDICAL HISTORY

ALL INFORMATION IS CONFIDENTIAL

The following information is required by the dentist to assist in proper diagnosis and treatment

1. Have you ever had a serious illness requiring hospitalization or extensive medical care? Yes No

Please specify

2. Are you presently under the care of a physician? Yes No

If so, please explain

3. Have you had a medical examination in the last year? Yes No

4. Do you use any prescription or non-prescription drugs regularly? Yes No

Please specify

5. Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex? Yes No

6. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea? Yes No

Please specify

7. Have you been hospitalized in the last 5 years? Yes No

Please specify

8. Have you ever experienced any unusual reaction to any of the following? Yes No

local anaesthesia (freezing) aspirin penicillin codeine sulpha drugs barbiturates (sleeping pills) or any other medicine?

If so please explain

9. Have you been warned against taking any drug or medication? Yes No

10. Do you bruise easily or bleed abnormally? Yes No

11. Do you require pre-medication for dental treatment? Yes No

12. Have you ever had any organ implants or medical implants? Yes No

13. Have you ever fainted? Yes No

14. Do your ankles swell? Yes No

15. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? Yes No

16. Do you have frequent headaches? Yes No

17. Do you have A.I.D.S. or have you ever tested positive for H.I.V.? Yes No

18. Do you have any of the following? Yes No

Please check any that apply

Heart Murmur or Mitral Valve Prolapse Stomach / Intestinal Problems / Ulcers Joint Replacement (hip, knee, etc.) Mental or Nervous Disorder High blood Pressure Low Blood Pressure Hyper (hypo) Glycemia Cortisone/Steroid Therapy

Malignant Hyperthermia Drug / Alcohol Dependency Venereal Disease Lung Disease (i.e. Asthma) Thyroid Disease Arthritis or Rheumatism Scarlet or Rheumatic Fever Cancer / Chemotherapy

Epilepsy or Seizures Liver Disease Heart Attack Cold Sores Jaundice Tuberculosis Hepatitis A,B,C

Herpes Sinus Trouble Stroke Kidney Problems Emphysema Glaucoma Diabete Other

Other

19. Have you had any injury, surgery or x-ray therapy to your face OF jaws? Yes No

20. Do you have any disease, condition, or problem that you think the doctor should know about? Yes No

21. WOMEN ONLY

Are you pregnant or suspect you might be? If so, what month are you in? Yes No

Are you taking birth control pills? Yes No

Are you nursing? Yes No

DENTAL HISTORY

1. Reason for today's visit Exam Cleaning Emergency Other Other

Are you presently having dental pain? Yes No

Is there a dental problem you would like to take care of as soon as possible? Yes No

Please specify

2. How frequently do you see your dentist? 6 months Yearly Other Other

Last dental visit

Last cleaning

Full mouth series of x-rays

3. How often do you brush your teeth? How often do you brush your teeth?

Floss?

4. Do your gums bleed easily? Yes No

5. Are your teeth sensitive to:

Hot Cold Biting Sweets?

Yes No

6. Do you feel you have bad breath at times? Yes No

7. Have you ever had jaw joint surgery? Yes No

8. Do you have pain in your jaw joints or suffer from migraine headaches? Yes No

9. Does any part of your mouth hurt when clenched? Yes No

10. Does your jaw crack or pop when opened widely? Yes No

11. Have you had:

Braces Oral surgery Gum treatment Root canal

Yes No

12. Do you grind or clench your teeth during the day or night? Yes No

13. Do you smoke? Yes No

Number per day

14. Do you or does any family member have a problem with snoring? Yes No

15. Have you ever experienced any growths or sore spots in your mouth? Yes No

If so, where?

16. Previous problems with dental treatment? Yes No

Specify

17. Are you satisfied with the appearance of your teeth? Yes No

Please specify

18. Other Dental Concerns Other Dental Concerns

Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 48 hours notice, otherwise it may be necessary to charge for the time lost.

Patient Release: I, the undersigned, certify that | have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. | have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependants is mine, and I will assume responsibility for fees associated with these services.

Signature (type in full name)

(Signature) Patient Parent Guardian

Date

11.21.2024

Reviewing Dentist

Dr. Lloyd G. Pedvis Dentistry Professional Corporation

I'm not a robot