4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

New Patient Registration Form

Personal Information

Salutation

First Name

Last Name

Address

City

Province

Country

Postal Code

Phone Number

Date of Birth

Family Physician

Physician's Phone Number

Emergency Contact

Emergency Contact Number

Relationship

Employer

Occupation

Spouse's First Name

Spouse's Last Name

Spouse's Phone Number

Spouse's Employer

Spouse's Occupation

Driver's License Number

Credit Card Number

Credit Card Type

Expiry Date

I hereby understand and agree that if any amount remains unpaid on my account, I authorize Sheppard Centre Dental to debit my credit card for the unpaid balance.

Insurance Information

Primary Insurance Company

Employee Name

SIN/Certificate #

Group Policy #

Secondary Insurance Company

Employee Name

SIN/Certificate #

Group Policy #

I authorize release to my insurance company and/or plan administrator, the information contained in claims submitted electronically.

Dental History

Former Dentist Name

Phone Number

Location

When was your last dental visit?

What was done at the time?

When was your last scaling (cleaning)?

When was the last time you had dental x-rays?

Have you ever had any of the following?

Do you have any of the following concerns when you smile?

	Yes	No
Are you nervous about dental treatments?
Are you having pain or discomfort at this time?
Have you noticed any loosening of your teeth?
Does food tend to get caught between your teeth?
Are your teeth sensitive to hot or cold?
Do you have problems with your jaw?
Do you floss regularly?
Do you drink coffee/tea?

If you answered yes to having problems with your jaw, please specify it here.

If you answered yes to having pain or discomfort at this time, please specify where.

If you answered yes to drinking coffee/tea, please specify how often.

How often do you brush your teeth a day?

Never

1-2

3-4

Medical History

When was your last medical checkup?

When was your last visit to a physician?

Please give reason:

	Yes	No
Have there been any changes in your general health in the past year?
Do you have any allergies?
Do you have any heart or blood pressure problems?
Do you have a heart murmur or mitral valve prolapse?
Have you ever had any rheumatic fever?
Have you ever been advised to take antibiotics prior to dental treatment?
Do you have or have you ever had jaundice, hepatitis or liver disease?
Have you ever been told that you should not give blood?
Do you have any conditions that could affect your immune system (i.e., HIV Positive, AIDS, Leukemia, etc.)?
Do you have a tendency to bruise easily or bleed for a prolonged period fo time after being cut?
Have you ever been hospitalized for any serious illnesses or operations?
Do you smoke or chew tobacco?
Are you being treated for any medical condition at the present or have you been treated within the last year?
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Have you ever had any peculiar or adverse reaction to any medicines or injections (i.e. penicillin, aspirin, local anaesthetics, dental freezing)?
Are there any conditions or diseases not listed above that you have or have had?

If you answered yes to being treated for any medical condition at the present or have been treated with the last year, please specify.

If you answered yes to taking any medications, non-prescription drugs or herbal supplements of any kind, please list.

If you answered yes to having any peculiar or adverse reaction to any medicines or injections (i.e., penicillin, aspirin, local anaesthetics, dental freezing), please list.

If you answered yes to any conditions or diseases not listed above that you have or have had, please list.

Patient Signature

Sign Here

Yonge Sheppard Centre Mall, 4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

Mon: 8:00 A.M. – 7:00 P.M.
Tue: 8:00 A.M. – 7:00 P.M.
Wed: 8:30 A.M. – 7:00 P.M.
Thu: 8:00 A.M. – 7:00 P.M.
Fri & Sat: 8:30 A.M. – 4:00 P.M.

Services

Contact Us

Book an Appointment

Fill the form below to schedule your appointment or call (647) 953-4630 for emergency.