New Patient Intake Form

Welcome to Bloor Dental Clinic. We look forward to getting to know you, your family and friends and caring for your dental health, with the goals of high quality and gentle dentistry in mind. We treat all our patients in the same manner as we would treat our families and ourselves. We will present you with your diagnosis and treatment options, honestly and openly, to help you make confident choices. We are proud of our safe and friendly environtment and dependable services.

In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you may have.

NOTE: Fields marked with an asterisk (*) are required.

ABOUT THE PATIENT

Title:

Patient Name:*

If the patient is a child, please state the name of the parent/guardian responsible for the account:

 
Date of Birth:* 

Sex:

CONTACT INFORMATION

Home Address:*

 

Phone Numbers:*

Email Address:*

Emergency Contact:*
Phone Number:*
Relationship:*
Whom may we thank for referring you to our practice?
Do you have Dental Insurance? Yes   No

If yes, please give your insurance information to the front desk.

MEDICAL HISTORY
Family Doctor:
Phone Number:

Are you presently being treated for any medical condition at the present or within the past 2 years?

 Yes   No 
If yes, please explain why:

Was your last medical checkup within the past year?

 Yes   No 

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

 Yes   No 

Are you currently taking any medications or non-prescription drugs of any kind?

 Yes   No 
If yes, please list:

Have you ever been warned against using any other medications?

 Yes   No 
If yes, please list:

Have you ever taken prolonged medical or non-medical drugs?

 Yes   No 
If yes, please list:

Are you allergic to any of the following?

Aspirin
Barbiturates (sleeping pills)
Codeine
Darvon
Local Anesthetic (Freezing)
General Anesthetic
Erythromycin
Penicillin
Clindamycin
Sulfonamide
Tetracycline
Injections
Jewelry/Metals
Latex
Other (please specify below)

Do you or did you smoke?

 Yes   No 
If yes, for how long?

Do you drink alcoholic beverages on a regular basis?

 Yes   No 

Do you use recreational drugs? (e.g. cocain or amphetamines)

 Yes   No 

(FOR WOMEN ONLY)

Are you taking birth control pills?

 Yes   No 

Are you pregnant?

 Yes   No 
If yes, when is your due date?

Do you bruise easily or have prolonged bleeding?

 Yes   No 

Have you ever fainted, had shortness of breath, or chest pains?

 Yes   No 

Do you have or have you had any of the following conditions. Please check all that apply:*

Aids
Anemia
Angina pectoris
Anorexia nervosa
Artificial Heart Valve
Arthiritis/rheumatism
Artificial joints (hips, knees)
Asthma
Blood Disorders
Bronchitis
Bulimia
Cancer
Circulation Problems
Congenital Heart Lesions
Cortisone/steroid
Diabetes
Drug/alcohol dependence
Emphysema
Epilepsy
Glandular Disorders
Glaucoma
Head/Neck Injuries
Heart Disease/Attack
Heart Murmur
Heart Pacemaker/surgery
Heart Rhythm Disorder
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
HIV Positive
Hodgkin's Disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung Disease
Malignant Hypothermia
Mental/Nervous Disorder
Mitral Valve Prolapse
Organ Transplant/Implant
Psychiatric Disorders
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Problems
Stroke
Thyroid Disease
Tuberculosis
Ulcers
Venereal Disease
Other
None of the above

Is there anything else we should know about your health?

DENTAL HISTORY

Previous Dentist:

Date of your last dental visit?  

Date of your last dental x-ray?  

How often do you have you teeth cleaned?  3-6 months  Annually  Other:

What is your IMMEDIATE dental concern?

Are you anxious during dental treatments?
(Please indicate by marking the scale)

 Not at all   1   2   3   4   5   Very anxious 

If you are nervous, would you like us to consider additional techniques along with "freezing" to help you?

 Yes   No 

Please select YES or NO to the following:

1. Are you satisfied with the appearance of your teeth?

 Yes   No 

If no, please specify:

2. Bleeding gums?

 Yes   No 

3. Avoid brushing any part of your mouth?

 Yes   No 

4. Are your teeth sensitive to temperature? (hot or cold)

 Yes   No 

5. Does food get caught between your teeth?

 Yes   No 

6. Sore teeth?

 Yes   No 

7. Burning sensation in your mouth?

 Yes   No 

8. Difficulty swallowing?

 Yes   No 

9. An unpleasant taste or odour in your mouth?

 Yes   No 

10. Dry mouth?

 Yes   No 

11. Jaw problems (temporomandibular joint or TMJ)?

 Yes   No 

12. Stiff neck muscles?

 Yes   No 

13. Tension headaches?

 Yes   No 

14. Clench or grind your teeth?

 Yes   No 

15. Lost any teeth?

 Yes   No 
CONSENT & POLICIES
  • I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform the office of any changes in my medical status.
  • I acknowledge that my dental benefits are my responsibility. I understand that I am responsible for payment of services rendered for my dependents and myself. Payment is due on the day of service rendered unless otherwise financially arranged. A fee of $45.00 is charged per NSF cheque.
  • My appointments are considered confirmed when scheduled. Bloor Dental Clinic requires a notice of 2 business days for any changes to my reserved appointment. A fee of $50.00 per appointment is charged for no-show, or short-noticed cancellation.
  • I give consent to the dental staff to provide the necessary diagnosis and treatment, and authorize the release of my information and my dependents' information to my dental insurance company/plan administrator for Electronic Dental Insurance (EDI) submission.
I have reviewed the information that explains how Bloor Dental Clinic will use my personal information, and the steps Bloor Dental Clinic will take to protect my information. I agree that Bloor Dental Clinic can collect, use and disclose personal information about my dependents and myself as set out in the information about the office privacy policies. I can ask to see these policies at any time.

Patient Name*:
Date*:
Patient Initials*: