New Patient Form

Reception desk at Sunrise Dentistry in Centennial Park Plaza, Etobicoke

For Patients

Welcome to
Our Office

To help us evaluate your dental health thoroughly and completely, please complete the following questionnaire before your first visit.

This form asks for personal health information, which will become part of your office record and will be held in strict confidence. If you have any questions, please call us at 416-626-0473.

SUNRISE DENTISTRY

Today's Date

WELCOME TO OUR OFFICE

In order to aid in evaluating your dental health thoroughly and completely, please complete the following examination questionnaire. This will become part of your office record and will be held in strict confidence.

Last Name

First Name

Name used

Home Address

Apt

City/Prov

Postal Code

Home Telephone

Bus.Telephone

Cell #

Birthdate

Employer

Occupation

Full Time Student

yesno

School

Whom may we thank for referring you?

Do you have Dental Insurance?

yesno

Name of subscriber

Subscriber birthday

Insurance Company

Group/Policy No

Subscriber's Employer

I.D. No

Relationship to Subscriber

Bus. Telephone

Subscriber is my

SpouseParent

Name of spouse or parent

Family Doctor

Telephone

DENTAL HISTORY

Do you have a specific dental problem at the moment?

yesno

Please describe the problem

Last dental visit. Date

Are you satisfied with the appearance of your teeth?

yesno

If not, why?

Primary Complaint

MEDICAL HISTORY

Have you ever had an unfavourable reaction following dental treatment? Please discuss this with the doctor.

yesno

Have you ever had excessive bleeding requiring special treatment? Please discuss this with the doctor.

yesno

Females patient, are you or could you be pregnant or nursing?

yesno

If yes, what month?

Are you taking any birth control pills?

yesno

Do you, or have you had any other diseases or medical problems not listed on this form?

List of Allergies

List of medications and reason for taking (include non-prescription drugs)

GENERAL RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required and I consent to my physician being contacted if necessary. I have also reviewed the privacy policies of the office regarding protection of my personal information. I understand that the responsibility for payment for the dental services provided for myself and or my dependants is mine and I will assume responsibility for fees associated with these services. I authorize release, to my dentist, information and authorize direct payment contained in claims submitted electronically.

Signature

Sign inside the box, or type your full name below.

Signed by

PatientParentGuardian

Print name of Guardian

New Patient Form

Welcome toOur Office

SUNRISE DENTISTRY

WELCOME TO OUR OFFICE

DENTAL HISTORY

MEDICAL HISTORY

GENERAL RELEASE

Welcome to
Our Office