New Patient Intake Form


A parent or guardian will be responsible for decisions on my treatment: Yes   |   No

Your Name:*

Date of birth:

Your Address:*

Contact Information:

Emergency Contact:
Phone Number:
Family Doctor:
Phone Number:
Referring Doctor:
Phone Number:

Method of Payment: Cash Debit Visa Mastercard Insurance
Person Responsible for Payment: Self Spouse Parent/Guardian Other
Do you have Dental Insurance?* Yes   |   No

If yes, please fill in the following insurance information. Otherwise, skip this section.

Primary Insurance Company

Insurance Year End: (usually Dec 31)

% Coverage For:

Secondary Insurance Company (if applicable)

In. Yr. End:

% Coverage For:


Medical History

Are you presently being treated by a physician?*

If yes, please explain why:

Are you taking any medications, pills, drugs, or medicine?

If yes, please list:

Do you suffer from any allergies (hay fever, latex, etc)?

If yes, please list:

Allergies: Have you ever had a reaction to any of the following?*

Penicillin Sulfonamide Asprin Barbiturates (sleeping pills) Codeine Darvon Local Anesthetic (Freezing) General Anesthetic No Drug Allergies other (please specifiy below)

Have you ever been warned against using any other medications?

If yes, please list:

Have you ever taken prolonged medical or non-medical drugs?

If yes, please list:

Do you bruise easily or have prolonged bleeding?

Have you ever fainted, had shortness of breath, or chest pains?

Do you smoke?

If yes, how much per day?

Are you pregnant?

Are you using birth control?

Do you have or have you had any of the following conditions. Please check all that apply:*

Aids
Anemia
Angina pectoris
Artificial Heart Valve
Arthiritis/rheumatism
Artificial joints (hips, knees)
Asthma
Blood Disorders
Cancer
Congenital Heart Lesions
Cortisone/steroid
Diabetes
Drug/alcohol dependence
Emphysema
Epilepsy
Heart Disease/Attack
Heart Murmur
Heart Pacemaker/surgery
Heart Rhythm Disorder
Hepatitis A/B/C
High/Low Blood Pressure
HIV Positive
Hyper (Hypo) Glycemia
Hypertension
Kidney Disease
Liver Disease
Lung Disease
Mitral Valve Prolapse
Organ Transplant/Implant
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Problems
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Other
None of the above

CHILDREN: Have you recently had any of the following (approximate date)?

Chicken Pox Measles Mumps
Strep Throat Tonsillitis None

Is there anything else we should know about your health?


Dental History

What is the reason for this visit? Emergency Examination Cleaning Other:

How frequently do you see your dentist? Every 3-6 months Annually Other:

Date of your last dental visit?

Date of your last X-Ray?

How often do you brush per day?
How often do you floss per day?

General Release:

I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as requiredx by this dental office. I authorize this dental office to perform diagnostic procedures as may be requiredx to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.

Did You Know?
Family Dentistry in Maple uses Digital Dental X-Rays?
Digital Dental X-Rays reduce exposure to harmful radiation by up to 75%.

Read more about the advantages of Digital Radiography click here.

   
OPEN 7 DAYS A WEEK
Monday 9am -
9pm
Tuesday 9am - 9pm
Wednesday 8am - 9pm
Thursday 9am - 8pm
Friday 9am - 7pm
Saturday 9am - 4pm
Sunday 9am - 1pm

NEW PATIENTS WELCOME
(905) 832-5000

MAPLE DENTAL OFFICE
10083 Keele Street, Lower Level
Maple, Ontario L6A 3Y8
(1 Block North of Major Mackenzie)

Sedation available for your comfort

FOR YOUR
CONVENIENCE

We Accept All major
Dental Plans Debit &
Credit Cards


INSURANCE CLAIMS
SUBMITTED FOR YOU!

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