Patient Form - Uplands Dental Clinic Thornhill

New Patients form

PATIENT INFORMATION

Title

Patient Name *

Date of Birth *

Age *

Gender *
MaleFemaleOther

Address (Street Name, Unit #) *

City *

Province *

Postal Code *

Primary Phone *

Secondary Phone

Preferred Contact Method *
PhoneEmail

Patient Email Address *

FAMILY PHYSICIAN INFORMATION

Family Physician Name

Physician Phone

Physician Email

EMERGENCY CONTACT INFORMATION

Emergency Contact *

Primary Phone *

Relationship *

MEDICAL INFORMATION

Do you have or have you ever had any of the following? (Check all that apply)

ADHDAIDS/HIVArthritisAsthmaAuto-ImmuneCancer (specify below)ChemotherapyChest Pain/AnginaCrohn's/IBS/GastritisDiabetesDrug/Alcohol DependencyEpilepsy - SeizuresEsophageal Re-flux (GERD)FaintingHead InjuriesHeart AttackHeart Disease/Heart MurmurHepatitisHigh Blood PressureInsulinJaundiceJoint Replacement (specify date below)Kidney DiseaseLiver DiseaseLow Blood PressureLung DiseaseMigraine HeadachesMitral Valve ProlapseOCD / Depression / Anxiety / mood disordersOn the spectrum/autismOsteoporosisPacemakerProsthetic Heart ValveRadiation TherapyRespiratory ProblemsSensory DisordersShortness of BreathSinus ProblemsStrokeThyroid ConditionTransplants (specify below)TuberculosisTumours (specify below)Other (specify details below)

Please specify any additional details to supplement the previous section...

Please list any medications/supplements being taken (attach a list if multiple)

Optional: Upload a list of medications (PDF, JPG, PNG):

Please list any known allergies

Please list any hospitalizations in the past 2 years

Please list any surgeries

Please list any recreational substances you take and frequency

Do you suffer from, or have a family history of malignant hyperthermia? *
YesNo

Are you taking blood thinners? *
YesNo

Do you have problems with your bleeding time? *
YesNo

WOMEN ONLY

Are you pregnant? *
YesNo

If yes, how many months?

Are you nursing? *
YesNo

DENTAL INFORMATION

When was your last dental visit?

What was the reason for your visit?

Are you having any problems that require immediate attention?

Are you nervous during dental treatment? *
YesNo

Do you currently have or have you ever had any of the following? (Check all that apply)

Bleeding gums when you brush your teethClenching/GrindingJaw PainLoose TeethOrthodontic TreatmentPeriodontal TreatmentSwelling of the face/neckSleep ApneaTemperature SensitivityTooth Pain

Are you interested in any of the following? (Check all that apply)

Bridge/DenturesDental ImplantsTeeth WhiteningDental CrownsStraightening Teeth

POLICY & GENERAL RELEASE

CANCELLATIONS AND MISSED APPOINTMENTS

Your appointment time has been exclusively for you... We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment...

GENERAL RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history...

I have read, understood, and agree to the General Release and Cancellation Policy above. *

Signature (Patient/Guardian) *

Date *

Dentist Signature (Office Use Only)
[text office-signature placeholder "To be signed upon arrival" readonly]

Date (Office Use Only)

New Patients form

PATIENT INFORMATION

FAMILY PHYSICIAN INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

WOMEN ONLY

DENTAL INFORMATION

POLICY & GENERAL RELEASE

CANCELLATIONS AND MISSED APPOINTMENTS

GENERAL RELEASE

Quick Links

Contact Info

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New Patients form

PATIENT INFORMATION

FAMILY PHYSICIAN INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

WOMEN ONLY

DENTAL INFORMATION

POLICY & GENERAL RELEASE

CANCELLATIONS AND MISSED APPOINTMENTS

GENERAL RELEASE

Status

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