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Welcome
to SCD
We are always welcoming new patients.
Please take a moment to provide us with the following information so we can ensure your SCD experience is an easy one.
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Personal Information
Personal Information
Salutation
*
Select an option
Mr.
Mrs.
Ms.
Miss.
First Name
*
Last Name
*
Address
*
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Street Number
Street Address
City
State
Country
Zip Code
Phone Number
*
Email
*
Date of Birth
*
Family Physician
Physicians Phone Number
Emergency Contact
Emergency Contact Phone Number
Relationship
Employer
Occupation
Spouse's First Name
Spouse's Last Name
Spouse's Phone Number
Spouse's Employer
Spouse's Occupation
Drivers License Number
Credit Card Number
Credit Card Type
Select an option
Visa
Mastercard
AMEX
Discovery
Expiry Date
Terms & Conditions
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.
I agree.
Insurance Information
Primary Insurance Company
Employee Name
SIN/Certificate #
Group Policy #
Secondary Insurance Company
Employee Name
SIN/Certificate #
Group Policy #
Terms & Conditions
I authorize release to my insurance company and/or plan administrator, the information contained in claims submitted electronically.
I agree.
Dental History
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?
Are you nervous about dental treatments?
Select an option
Yes
No
Are you having pain or discomfort at this time?
Select an option
Yes
No
If so, where?
Have you ever had any of the following?
Press ctrl or ⌘ (in Mac) while clicking to select multiple options.
Orthodontic Treatment
Oral Surgery
Periodontal Surgery
None
Select any or all that apply.
Have you noticed any loosening of your teeth?
Select an option
Yes
No
Does food tend to get caught between your teeth?
Select an option
Yes
No
Are your teeth sensitive to hot or cold?
Select an option
Yes
No
Do you have problems with your jaw?
Select an option
Yes
No
Please specify
Do you have any of the following concerns when you smile?
Press ctrl or ⌘ (in Mac) while clicking to select multiple options.
White Teeth
Crowding
Other
None
Select any or all that apply.
How often do you brush your teeth a day?
Select an option
Never
1-2
3-4
5+
Do you floss regularly?
Select an option
Yes
No
Do you drink coffee/tea?
Select an option
Yes
No
How often?
Do you eat sweets?
Select an option
Yes
No
How often?
Medical History
Medical History
Are you being treated for any medical condition at the present or have you been treated within the last year?
*
Select an option
Yes
No
Please specify:
*
When was your last medical checkup?
When was your last visit to a physician?
Please give reason:
*
Have there been any changes in your general health in the past year?
*
Select an option
Yes
No
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
*
Select an option
Yes
No
Please list:
*
Do you have any allergies?
*
Select an option
Yes
No
Please list:
*
Have you ever had any peculiar or adverse reaction to any medicines or injections (i.e. penicilin, aspirin, local anaesthetics, dental freezing)?
*
Select an option
Yes
No
Do you have any heart or blood pressure problems?
*
Select an option
Yes
No
Do you have a heart murmur or mitral valve prolapse?
*
Select an option
Yes
No
Have you ever had any rheumatic fever?
*
Select an option
Yes
No
Have you ever been advised to take antibiotics prior to dental treatmen?
*
Select an option
Yes
No
Do you have or have you ever had jaundice, hepatitis or liver disease?
*
Select an option
Yes
No
Have you ever been told that you should not give blood?
*
Select an option
Yes
No
Do you have any conditions that could affect your immune system (i.e. HIV Positive, AIDS, Leukemia, etc.)?
*
Select an option
Yes
No
Do you have a tendency to bruise easily or bleed for a prolonged period fo time after being cut?
*
Select an option
Yes
No
Have you ever been hospitalized for any serious illnesses or operations?
*
Select an option
Yes
No
Do you have or have you ever had any of the following? (Please check off only those that apply)
Chest pain
Arthritis
Epilepsy
Asthma
Prosthetic joint
Bronchitis
Heart attack
Diabetes
Stomach ulcers
Drug/alcohol dependency
Tuberculosis
Emphysema
Stroke
Kidney disease
Are there any conditions or diseases not listed above that you have or have had?
*
Select an option
Yes
No
Please list:
*
Do you smoke or chew tobacco?
*
Select an option
Yes
No
Are you pregnant ? (For women only)
*
Select an option
Yes
No
Not sure/Maybe
Signature
Please upload a digital copy of your signature to verify all information is correct.
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