Patient Registration

PERSONAL INFORMATION

Name:

Salutation: Miss Mrs. Ms. Mr. Dr.

Date of Birth:

Age:

Gender: Female Male

Email:

Home Address:

City:

Province: Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Postal Code:

Primary Phone:

Secondary Phone:

Occupation:

Employer:

Work Phone:

Spouse's Name:

Who will be responsible for the payment of your account (Name)

Who will be responsible for the payment of your account (Address)

Who may we thank for referring you to our office?

Do you have a general dentist? Yes No

Dentist's Name

HEALTH HISTORY

Family Physician's Name

Family Physician's Telephone

Have there been any problems in your general health within the last five years? (serious illness, hospitalization, surgery, etc)? No Yes

If yes, what was the problem?

Do you smoke? No Yes

Number of packs per day:

Do you have, or have you had, any of the following diseases or problems?

Are there any other medical conditions we should be aware of?

What medications do you take? (include aspirin, etc)?

Any allergies to medications or substances such as latex? Please specify.

Do you require antibiotics prior to any dental treatment? Please specify.

Do you react to local anaesthetic? Please describe.

Emergency Contact Name:

Emergency Contact Telephone:

ORAL HEALTH

1. No Yes Do you have pain around your ears, eyes or other parts of your face?
2. No Yes Do you clench or grind your teeth while awake or asleep?
3. No Yes Are you aware of any sores or lumps in your mouth at present?
4. No Yes Do you ever hear grating or popping sounds from your jaw joint?

IMPLANTS

Do you have implants? No Yes

Date of Placement:

Name of the surgeon who placed the implants:

PATIENTS WITH FULL OR PARTIAL DENTURES

1. Please indicate the type(s) of denture you wear:

   Partial Denture: Upper
   Lower

   Full Denture: Upper
   Lower

2. Do you have any problems with your full or partial dentures? No Yes

   If yes, please describe:

3. When were your dentures made?

   Upper:

   Lower:

4. Are you satisfied with the appearance of your dentures? No Yes

5. Are you interested in information on IMPLANTS to replace your denture(s)? No Yes

When receiving dental treatment, which best describes you? Relaxed
Mildly Apprehensive
Very Nervous But Under Control
Extremely Apprehensive

What are your present dental problems? (360 chars max)

What concerns you about receiving dental therapy? (360 chars max)

Please be advised that your records may be shared with another dental office if a registration is required for your dental treatment, and only required information will be forwarded to your insurance company.

Should you need to reschedule or cancel your appointment, we require 2 working days notice to avoid a late fee.

Payment is expected at the time the services are rendered or initiated. Our office does not take assignment on insurance plans, but we are happy to fill out your documents so that you are able to submit for any coverage that your plan may provide. We accept cash, Visa, MasterCard and Debit.

* To the best of my knowledge, the questions on this form have been accurately answered.

* I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status; if ever I have any change in my health condition or the medications I take, I will inform the Doctor on my next appointment without fail. I also understand that I am fully responsible for the financial aspect of my dental treatment to Anh Nguyen Dentistry Professional Corporation.