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Your Name (required): Salutation: MissMrs.Ms.Mr.Dr.
Date of birth (YYYY-MM-DD) (required):
Age (required):
Gender (required): —Please choose an option—FemaleMaleNon- Binary
Your Email:
Your Address (required):
City (required):
Province (required): —Please choose an option—OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaPEIQuebecSaskatchewanNWTNunavutYukon
Postal Code (required):
Home Phone (required) - Do Not Include Dashes:
Mobile Phone:
Occupation:
Employer:
Work Phone:
Partners Name:
Who may we thank for referring you to our office?
Do you have a general dentist? YesNo Dentists Name:
Family Physicians Name: Family Physicians Telephone:
Have there been any problems in your general health within the last five years? (serious illness, hospitalization, surgery, etc)? NoYes
Do you smoke? (required): NoYes Number of packs per day:
"Rheumatic fever, rheumatic heart disease" NoYes
"Heart trouble, heart attack, high blood pressure, stroke" NoYes
"Radiation or treatment for a tumour or other growth" NoYes
"Blood disorders, anemia" NoYes
"Abnormal bleeding, prolonged healing" NoYes
"Fainting spells, seizures" NoYes
"Migraines or tension headaches" NoYes
"Hepatitis, jaundice, liver disease" NoYes
"AIDS, HIV, autoimmune deficiencies" NoYes
"Sleep Apnea" NoYes
"Kidney trouble" NoYes
"Diabetes" NoYes
"Psychiatric disorders" NoYes
"Special needs" NoYes
"Asthma, hayfever" NoYes
"Low blood pressure" NoYes
"Artificial joints" NoYes
"Are you currently pregnant?" NoYes
"Osteoporosis" NoYes
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 (required):
Emergency Contact Telephone (required):
Do you have pain around your ears, eyes or other parts of your face? NoYes Do you clench or grind your teeth while awake or asleep? NoYes Are you aware of any sores or lumps in your mouth at present? NoYes Do you ever hear grating or popping sounds from your jaw joint? NoYes
Do you have implants? NoYes Date of placement (YYYY-MM-DD): Name of surgeon who placed the implants:
Please indicate the type(s) of denture you wear: Partial UpperPartial Lower Full UpperFull Lower
Do you have any problems with your full or partial dentures? —Please choose an option—NoYes
When were your dentures made?
Upper (YYYY-MM-DD): Lower (YYYY-MM-DD):
Are you satisfied with your dentures? —Please choose an option—NoYes
Are you interested in information on implants to replace your denture(s)? NoYes
When receiving dental treatment, which best describes you? RelaxedMildly ApprehensiveVery Nervous But Under ControlExtremely Apprehensive
What are your present dental problems?
What concerns you about receiving dental therapy?
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.