Welcome, and thank you for choosing us for your prosthetic treatment. We will strive to do our best to provide you with the finest care. If you have any questions about our office or this form, please do not hesitate to contact us.
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
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:
Rheumatic fever, rheumatic heart disease
Kidney trouble
Heart trouble, heart attack, high blood pressure, stroke
Diabetes
Radiation or treatment for a tumour or other growth
Psychiatric disorders
Blood disorders, anemia
Special needs
Abnormal bleeding, prolonged healing
Asthma, hayfever
Fainting spells, seizures
Low blood pressure
Migraines or tension headaches
Artificial joints
Hepatitis, jaundice, liver disease
Are you currently pregnant?
AIDS, HIV, autoimmune deficiencies
Osteoporosis
Sleep Apnea
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:
Do you have implants? No Yes
Date of Placement:
Name of the surgeon who placed the implants:
Please indicate the type(s) of denture you wear:
Partial Denture: Upper Lower
Full Denture: Upper Lower
Do you have any problems with your full or partial dentures? No Yes
If yes, please describe:
When were your dentures made?
Upper:
Lower:
Are you satisfied with the appearance of your dentures? No Yes
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.