New Patient Form Step 1 of 5 - Patient Info20%Patient InfoFirst NameLast NameInitialPrefers to be CalledBirth DateAgeMarital StatusThe patient is an: Adult Child Adult Under GuardianshipGuardianPatient Status: Dr. Mr. Mrs. Ms. MissSex: Male FemaleContact InfoAddressApt#CityProvincePostal CodeBus. PhoneHome PhoneCell PhoneMay we call you at work? Yes NoEmail Employer InfoEmployerOccupationWhom may we thank for referring you?Person responsible for accountS.I.N of this person Medical PriorityFamily PhysicianAddressPhoneAre you under the care of a Medical Specialist? Yes NoIf yes, please fill out the section below:Type of SpecialistNameAddressPhoneIn case of emergency, please contact:NamePhone Insurance InformationDo you have an insurance Yes NoIf yes, please fill out the section below:Insurance Co. NameHolder's NameName of SpouseBirthdate of Ins. HolderPolicy No.Certificate No.Group No.Division No.Max Coverage Yearly ($)Percent CoveragePercent DeductibleSecond InsuranceDo you have two insurance policies Yes NoIf yes, please fill out the section below:2nd Insurace Co. NameHolder's NameBirth Date of Ins. HolderPolicy No.Certificate No.Group No.Division No. Health HistoryAre you currently receiving care from a physician? Yes NoWere you ever seriously ill or hospitalized? Yes NoAre you currently on any drugs or medications? Yes NoPlease indicate if you have a serious reaction to any of the following medication: Antibiotics Sleeping pills Codein DarvonPlease let us know if you have been warned against taking any medication Yes NoHave you ever used any medical or non-medical drugs on a regular basis? Yes NoDo you have any allergies we should know about? Yes NoAre you a smoker? Yes NoHave you ever fainted, felt out of breath, or had chest pains? Yes NoPlease indicate if you have or had any of the following: A.I.D.S Cortisone/Steriod High/Low blood pressure Osteoporosis Alcohol Dependence Diabetes H.I.V positive Psychiatric treatment Anemia Drug dependence Hodgkins disease Radiation/Chemotherapy Angina pedoris Emphysema Hyper (Hypo) glycemia Rheumatic/Scarlet fever Anorexia nervosa Epilepsy or seizures Hypertension Sickle cell disease Arthritis/rheumatism Glandular disorder Jaundice Sinus trouble Artificial heart valve Glaucoma Kidney disease Stomach/intestinal Artificial joints Head/neck injuries Liver disease Stroke Asthma Heart disease Leukemia Thyroid disease Blood disorder Heart murmur Lung disease Tuberculosis Bronchitis Heart pacemaker/surgery Malignant hyperthemia Ulcers Bulimia Heart rhythm disorder Mental disorder Venereal disease Cancer Hepatitis A/B/C Mitral valve prolapse Other Circulation problems Herpes Organ transplant/implant None Congenital heart lesionsWomenAre you pregnant? Yes NoMenopause? Yes NoBirth Control? Yes NoChildrenPlease indicate any of the following: Chicken Pox Measles Mumps Strep Throat Tonsilitis Dental HistoryPlease indicate the reason for today's visit: Examination Emergency OtherApproximately how often do you see the dentist?How often do you brush?Are your teeth sensitive to: Cold Sweets Heat OtherHave your gums bled when brushing or flossing? Yes NoDo your gums feel swollen or tender? Yes NoDo you feel that you have a bad breath? Yes NoDo you experience any popping/clicking in your jaw joints? Yes NoDo you grind or clench your teeth? Yes NoDoes food catch between your teeth? Yes NoHave you ever had local anesthetic (freezing)? Yes NoHave you ever had complications due to anesthetics? Yes NoPlease indicate if you had any of the following treatments done Crown or Caps Full or partial dentures Periodontal (Gums) Bridgework/Orthodontics (Braces) Root CanalAre you dissatisfied with the appearance of your teeth? Yes NoPrivacy Consent and General Release:Privacy of your personal information is as important part of your office as providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and clear as possible about the way in which we handle your personal information. All our staff members who come into contact with your personal information are trained in the appropriate uses and protection of your personal information. I, the undersigned, understand that the data contained in the dental and medical history portion of this chart is important to treatment. I certify that all the information is correct and that I have not knowingly omitted data. I consent to the release of medical information my medical doctor or other health provider as is required by World Dental Clinic. I authorize World Dental Clinic to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.