New Patient Registration Form

Personal Information

Insurance Information

Dental History

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?

Medical History

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?
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Book an Appointment

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