Medical History – Crystal Dental

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Medical History

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Patient Information

Patient Last Name *

Patient First Name *

Middle Initial

Birth Date *

Age *

Street Address *

Apartment Number

City *

Province *

Postal Code *

Home Phone *

Work Phone

Ext:

Cell Phone

Health Card #

Email address

Family Physician

Phone

Preferred Appointment Times *

Morning Afternoon Evening Anytime

Preferred Appointment Day *

Monday Tuesday Wednesday Thursday Friday

How would you rate your smile? * From 1-10

Employment Information

Employer Name

Occupation:

Phone #

Responsible Party Information Insurance Information

Party responsible for payment *

Self Other

Primary

Name of Insured

Is insured a patient?

Yes No

Insurance Company

Insured's Birth Date

ID #

Group #

Patient's relationship to insured:

Secondary

Name of Insured

Is insured a patient?

Yes No

Insurance Company

Insured's Birth Date

ID #

Group #

Patient's relationship to insured:

Health Information

Date of Last Dental Visit: *

Reason for today's visit *

Do you or have you ever had an adverse reaction or allergy to:

Local Anesthetics/Novocain Aspirin/Advil Codeine Latex Antibiotic Other

Do you take:

Blood thinners (e.g Coumadin, Plavix, etc.) Any other medications, vitamins or supplements

What is your level of anxiety/stress/fear when going to the dentist? *

Other medical conditions * Check all that apply

Asthma Tuberculosis Vertigo Bleeding problems Chemo/radiation Artificial joint Hepatitis Psychiatric therapy Thyroid disease Cancer Heart disease Steroid use Kidney problems Prosthetic heart valve Any addiction Breathing/COPD HIV/AIDS Cold sores/fever blisters Surgery Sleep apnea Diabetes Epilepsy Change in health in last year None of the above

Specify any of the above conditions:

Have you ever had any complications following dental treatment? *

Yes No

Have you been admitted to a hospital or needed emergency care during the past two years? *

Yes No

If you are covered under Ontario Disability (ODSP) please specify your disability

Are you pregnant or is it possible you are pregnant? *

Yes No

Are you now under the care of a physician? *

Yes No

Do you have any health problems that need further clarification? *

Yes No

Do you smoke? *

Yes No

If you used to smoke, when did you quit?

Do you use recreational drugs? *

Yes No

Do you take antibiotics prior to dental work or surgery? *

Yes No

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. *

Referral Information

Whom may we thank for referring you to our practice? *

Dental office Newspaper Internet Walk-by/location Yellow Pages Other Work

Name of person or office referring you to our practice

Consent for Services/ Office Agreement

* I understand that my family's appointments are valuable and that 2 Business days notice must be given if we are unable to attend appointments.

* I will be required to pay for my/my family's treatment at each visit.

* Outstanding account balances may be passed to collections if unpaid.

* Crystal Dental accepts Visa, MasterCard, Debit or Cash.

* Crystal Dental will propose treatment with your long-term dental health in mind and provide accurate estimates.

I have read the above conditions of treatment and payment and agree to their content. *

How Our Office Collects, Uses and Discloses Patient's Personal Information

Crystal Dental understands the importance of protecting your personal information.

To deliver safe and efficient patient care
To identify and ensure continuous high quality service
To assess health needs and advise treatment options
To communicate with specialists and referral providers
To complete insurance claims and billing
To collect unpaid accounts
To comply with applicable laws

By completing this patient consent form, you agree to the collection and use of personal information for the purposes listed above. *

Name *

Date *

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Contact Details

Unit 302 – 875 St David Street North, Fergus, ON

+1 (226)-897-1016

care@crystal-dental.ca

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