Patient Registration Form - Bloor Dental Clinic

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 of 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 our self and friendly environment, dependable and punctual services

About the patient

First name: *

Last name: *

Preferred name:

birthday:

Marital status:

Email: *

Home address:

City:

Province:

Postal code:

Home phone#:

Work phone#:

Ext:

Other

where and when are the best times to reach you?

occupation:

person responsible for account:

Relationship:

emergency contact:

Relationship:

Phone#:

Whom may we thank for reffering You to our practice?

Other family members seen by us:

Patient is a child

An Adult under guardianship

Who is the patient today?

Relation

Mother's name:

Work #:

Father's name:

Work #:

Legal guardian:

Work #:

Do you ha dental insurance?
YesNo

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

Dental History

Why have you come to the dentist today?

Are you currently in pain?
YesNo

Please explain

Do you brush twice a day?
YesNo

Do you floss daily?
YesNo

Do you use mouthwash?
YesNo

Other

Doy you have any of the following?

Bleeding gums
YesNo

Food caught in your teeth
YesNo

Sensitive teeth?
YesNo

Loose teeth?
YesNo

How would you rate your previous dental experience? 1. Being relaxed 5. Extremely nervous

Previous dentist:

Last visit date:

Reasons:

Medical History

Physicians name:

Address:

Phone #:

Specialist's name:

Address:

Phone #:

Specialist's name:

Address:

Phone #:

have you been under medical care within the past two years
YesNo

Reasons

have you been under medical care within the past two years
YesNo

Reasons

when was your last physical exam?

Result:

when was your last visit to a physician?

Reason:

Medical History Cont.

Do you or have you ever experienceed the following? Pleace indicate
YesNo

BP:

HR:

Others

Pleace explain

Women Only:

are you taking birth control pills?
YesNo

are you pigment
YesNo

Number of months?

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 changed 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 changed for no-show, or short notice cancellation.
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 & myself as set out in the information about the privacy policies. I can ask to see these policies at any time.
I give consent to that dental staff to provide the necessary diagnosis and treatment, and authorize the release of my information and my dependents to information my dental insurance company/plan administrator for Electronic Dental Insurance (EDI) submission.

we are pleased to answer any questions you may have or receive your feedback thank you for joining our dental family at Bloor Dental Clinic