HOME / PATIENT INTAKE

New patient
intake form.

Save time in the waiting room. Complete your forms online before your first visit. It takes about 10 minutes.

Patient information

The information that is requested on this questionnaire is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly. Fields marked * are required.

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Insurance & contacts

Your insurance, family physician and emergency contact.

Do you have insurance? *

Please choose Yes or No.
Family physician

Are you under the care of a Medical Specialist? *

Please choose Yes or No.
In case of emergency, please contact
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Health history

Please check YES or NO to each question.

Please check YES or NO to each question.

1. Are you being treated for any medical condition at present or within the past year? *

Please choose Yes or No.

2. Has there been any change in your general health in the past year? *

Please choose Yes or No.

3. When was your last visit to a Physician? Last complete physical examination?

4. Have you recently, or are you presently, taking any PRESCRIPTIONS or NON-PRESCRIPTION DRUGS? (Including herbal remedies) *

Please choose Yes or No.

5. Have you ever had any adverse or unusual reactions to any medications or injections? (E.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic (“dental freezing”)) *

Please choose Yes or No.

6. Have you ever been advised against taking any specific type of medication? *

Please choose Yes or No.

7. Do you have any allergies? (E.g. hay fever, food allergies, and latex/rubber or metal allergies?) *

Please choose Yes or No.

8. Do you have epilepsy or seizures? *

Please choose Yes or No.

9. Have you ever fainted during dental or medical treatment? *

Please choose Yes or No.

10. Do you bleed excessively from a cut or injury, bruise easily or have blood disorders? *

Please choose Yes or No.

11. Are you on any cortisone or steroid therapy, or are you on diet pill therapy? *

Please choose Yes or No.

12. Do you have any artificial joints? (Hip, knee, etc.) *

Please choose Yes or No.

13. Indicate which of the following you presently have, or ever had (please check any applicable):

14. Do you, or did you smoke? *

Please choose Yes or No.

15. Do you drink alcoholic beverages on a regular basis? *

Please choose Yes or No.

16. Use recreational drugs? *

Please choose Yes or No.

17. Do you currently have, or ever had in the past, any disease, conditions or problems not listed above? *

Please choose Yes or No.

18. Are there any diseases or medical problems that run in your family? (E.g. diabetes, cancer, heart disease) *

Please choose Yes or No.

19. Is there anything else about your health we should be made aware of; or do you wish to speak to the doctor privately about any problem or medical condition? *

Please choose Yes or No.
Women only

20. Are you taking birth control pills?

Please choose Yes or No.

Are you breastfeeding?

Please choose Yes or No.

Are you pregnant?

Please choose Yes or No.

Women over 50: Are you aware of your bone mineral density?

Please choose Yes or No.

Dental history

Your dental history helps us plan your care.

4. Do you feel you have bad breath? *

Please choose Yes or No.

5. Do you use dental floss? *

Please choose Yes or No.

Proxabrush? *

Please choose Yes or No.

Stimudents? *

Please choose Yes or No.

6. Are your teeth sensitive to heat, cold or sweets? *

Please choose Yes or No.

7. Have you ever had:

Periodontal treatment? (treatment of the gums) *

Please choose Yes or No.

Orthodontic treatment? *

Please choose Yes or No.

Bite plate or other appliances? *

Please choose Yes or No.

Bite adjustment? *

Please choose Yes or No.

Oral surgery? *

Please choose Yes or No.

9. Have you ever had an upsetting experience in a dental office, or any complications during or following dental treatment? *

Please choose Yes or No.

General release

Please read the release below, then sign.

General releaseI, the undersigned, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any changes in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents are mine and I assume responsibility for fees associated with these services.
Please confirm you agree to the general release.
Signed by the *
Please choose an option.
Please fill in this field.

Review & submit

Take a quick look. You can go back to edit anything.

All done

Thank you, friend.

Your intake form has been received. Our team will review it before your visit. Just bring your insurance card and photo ID.

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