Patient Intake Form

Patient Intake Form

Welcome to Dentistry on Liverpool
Please complete the following questions to the best of your ability. All information is strictly confidential and is essential to providing you with the highest standard of dental care.
Title*
Given Name*
Last Name*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Age*
Sex*
Place of Birth
Date of Birth*

MonthDayYear
Date
Height*
Weight*
Tel: Cellular*
Please enter a valid phone number.
Tel: Residence
Please enter a valid phone number.
Tel: Business
Please enter a valid phone number.
Email*
example@example.com
Occupation
Place of Business
How did you hear about us?*
Referred By
Family Physician: Name*
Family Physician: Phone Number*
Please enter a valid phone number.
Family Physician: Address

Street Address

Street Address Line 2

CityProvince

Postal Code
In case of Emergency, Please Notify:
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Medical History
1. Are you presently under the care of a physician?*

YesNo
2. Have you experienced changes in your health recently?*

YesNo
3. Have you ever been hospitalized?*

YesNo
Explain/Specify
4. When was your last visit to a physician?*
Last complete physical examination?*
5. Are you presently taking any kind of medication?*

YesNo
Specify
a. Drug
Reason
b. Drug
Reason
c. Drug
Reason
d. Drug
Reason
e. Drug
Reason
f. Drug
Reason
6. Have you ever had an adverse reaction to any medication?*

YesNo
7. Do you have any allergies?*

YesNo
Specify:
8. Do you have heart or circulatory problems of any kind?*

YesNo
9. Do your ankles, feet, or hands swell?*

YesNo
10. Do you experience shortness of breath or chest pain when walking or climbing stairs?*

YesNo
11. Have you ever had rheumatic fever?*

YesNo
12. Do you bleed excessively from a cut or injury or bruise easily?*

YesNo
13. Have you ever had an injury or surgery to your face or jaws?*

YesNo
14. Do you have any hearing difficulties?*

YesNo
15. Do you smoke or use other tobacco products?*

YesNo
16. Are you alcohol and/or drug dependent?*

YesNo
17. Do you presently, or have you ever had:

AnaemiaAngina PectorisArthritisArtificial Heart ValveArtificial Joints (Hip, Knee)AsthmaBlood DisordersCancerCrohns / ColitisDiabetesEpilepsy or SeizuresHay FeverHeart Disease / AttackHeart MurmurHeart PacemakerHeart Rhythm DisorderHepatitisHigh/Low Blood PressureHIV/AIDSHyper/Hypo GlycemiaKidney DiseaseLiver DiseaseLung DiseaseMalignant HyperthermiaMental or Nervous DisorderMigraine HeadachesOrgan Transplant / MedicalImplantRheumatismScarlet FeverSinus ProblemStomach / Intestinal ulcerStrokeThyroid DiseaseTuberculosisVenereal Disease
18. Have you ever had any illness not included above?*

YesNo
Specify
Medical Update
19. Have you been advised to take antibiotics before a dental appointment?*

YesNo
Children Only:
20. Has the patient recently had any of the following?

YesNo
Specify

MeaslesMumpsChicken PoxStrep ThroatTonsillitis
Women Only:
21. Are you pregnant?

YesNo
22. What is the expected delivery date?
23. Are you taking birth control pills?

YesNo
Note: It is important that we are made aware of any change in your health status.
Dental History
1. Is there a dental problem that you would like treated immediately?*

YesNo
2. How frequently do you see your dentist?*
3. Have you ever been given oral hygiene instruction in:

BrushingFlossingOther
4. Have you ever had local anaesthetic?*

YesNo
Any Complications?
5. Are there any growths or sore spots in your mouth?*

YesNo
6. Do your gums bleed when:*

BrushingFlossingSpontaneouslyNo BleedingOther
7. Do your gums feel swollen or tender?*

YesNo
8. Are you sensitive to:*

ColdSweetsHeatNo Sensitivities
9. Do you catch food between your teeth?*

YesNo
10. Are you aware of any loose teeth?*

YesNo
11. Do you use:

Dental FlossProxabrushOther
How Often?
12. How often do you brush your teeth?*
13. Do you feel that you have bad breath?*

YesNo
14. Does your jaw crack, pop or grate when you open widely?*

YesNo
15. Do you grind or clench your teeth?*

YesNo
16. Have you ever had any of the following?

Periodontal TreatmentOrthodontic TreatmentA Bite ApplianceOral Surgery / Implants
17. Are you being followed up by a specialist?*

YesNo
18. Are you happy with the appearance of your teeth? What would you like to see changed?*
Dental Update
Dental Insurance*

YesNo
Employer Name
Name of Insurance Company
Policy/Plan Number
Certificate/ID Number
Are you the policy holder?

YesNo
Name of Policy Holder
DOB of Policy Holder
Relationship to Policy Holder

SpouseDependentOther
Do you have Secondary Insurance?

YesNo
2. Employer Name
2. Name of Insurance Company
2. Policy/Plan Number
2. Certificate/ID Number
2. Are you the policy holder?

YesNo
2. Name of Policy Holder
2. DOB of Policy Holder
2. Relationship to Policy Holder

SpouseDependentOther
PATIENT CERTIFICATION AND APPROVAL

I, the undersigned, certify that all the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.
Cancellation Policy

We value your time and appreciate that your schedule may change. We expect at least 48 hours' notice for any changes to your appointment. In order to provide our patients with efficient and cost-effective care, appointments missed without adequate notice may result in a fee applied to your account.
Patient (Parent, Guardian) Signature*

Clear
Date

MonthDayYear
Date
PATIENT CONSENT OR GUARDIAN CONSENT FOR MINORS

I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated, and I will assume responsibility for fees associated with these procedures.
Patient (Parent, Guardian) Signature*

Clear
Date

MonthDayYear
Date
PERMISSION TO SEND CLAIMS EDI

(if I have dental insurance)
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Intake Form

In case of Emergency, Please Notify:

Medical History

Children Only:

Women Only:

Dental History

PATIENT CERTIFICATION AND APPROVAL

PATIENT CONSENT OR GUARDIAN CONSENT FOR MINORS

PERMISSION TO SEND CLAIMS EDI