Patient Registration Form - Bloor Dental Clinic

Patient Information

*All fields required

Welcome to Bloor Dental Clinic. We look forward to getting to know you, your family, and your 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.

Salutation*

First Name*

Last Name*

Preferred Name

Date of Birth*

Marital Status*

Registering for child?*

Yes

Person responsible for account:*

Other parental consent required:*

Yes

Mother’s name*

Contact Number*

Father’s name*

Contact Number*

Contact Information

Email*

Address*

Street Address City Province Postal Code

Home Phone

Cell Phone*

Work Phone

Ext.

In case of emergency, please notify:

Name*

Relation*

Home Phone*

Cell Phone*

Work Phone

Contact Options

I prefer appointment reminders by*

Phone

Whom may we thank for referring you?

Are any other members of your family patients at our practice?*

Yes

Please list:

Insurance Information*

Yes, insurance applies to me

No, insurance does not apply to me

Please complete the following if you have dental insurance

Name of insured/subscriber*

Date of Birth*

Patient's relationship to subscriber*

Self

Spouse

Child

Place of employment*

Insurance Company*

Policy/Group#*

Certificate/ID#*

I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations*

Yes

Dental History

Why have you come to the dentist today?*

Are you currently in pain?*

Yes

Please Explain:*

Do you brush twice a day?*

Yes

Do you floss daily?*

Yes

Do you use mouthwash?*

Yes

Other:*

Do you have any of the following?

Bleeding gums*

Yes

Not Sure

Food Caught in your teeth*

Yes

Not Sure

Sensitive teeth*

Yes

Not Sure

Loose teeth*

Yes

Not Sure

How would you rate your previous dental experience?

1. Being Relaxed 5. Extremely Nervous

Are you happy with the appearance of your teeth?*

Yes

Not Sure

What would you change?

Previous Dentist:

Last Visit Date

Reasons:

Medical History

Physician's Name:

Address:

Phone Number:

Specialist's Name:

Address:

Phone Number:

Specialist's Name:

Address:

Phone Number:

Have you been under medical care within the past two years?*

Yes

Reasons:*

When was your last physical exam?

Result:

When was your last visit to a Physician?

Reason:

Do you have or have you ever experienced the following?

Abnormal bleeding*

Yes

Not Sure

Abnormal bruising*

Yes

Not Sure

Blood transfusion*

Yes

Not Sure

Blood disorder*

Yes

Not Sure

Hemophilia*

Yes

Not Sure

Liver disease*

Yes

Not Sure

Jaundice*

Yes

Not Sure

Hepatitis A B C*

Yes

Not Sure

Sickle cell anemia*

Yes

Not Sure

Anemia*

Yes

Not Sure

Prostate problems*

Yes

Not Sure

Head/neck injuries*

Yes

Not Sure

Headaches/migraines*

Yes

Not Sure

Sinus problems*

Yes

Not Sure

Glaucoma/Cataract*

Yes

Not Sure

Artificial joints*

Yes

Not Sure

Seizures/Epilepsy*

Yes

Not Sure

Arthritis/Rheumatism*

Yes

Not Sure

Lupus*

Yes

Not Sure

Organ transplant*

Yes

Not Sure

Colitis/Ulcers*

Yes

Not Sure

Ever hospitalized*

Yes

Not Sure

Alcohol / drug abuse*

Yes

Not Sure

Steroid therapy*

Yes

Not Sure

Cancer*

Yes

Not Sure

Radiation treatment*

Yes

Not Sure

Chemotherapy*

Yes

Not Sure

Venereal disease*

Yes

Not Sure

Herpes*

Yes

Not Sure

Immune problems*

Yes

Not Sure

HIV/AIDS*

Yes

Not Sure

Mitral Valve Prolapse*

Yes

Not Sure

Psychological problems*

Yes

Not Sure

Malignant hyperthermia*

Yes

Not Sure

Tuberculosis (TB)*

Yes

Not Sure

Persistent cough*

Yes

Not Sure

Emphysema*

Yes

Not Sure

Asthma*

Yes

Not Sure

Lung problem*

Yes

Not Sure

Shortness of breath*

Yes

Not Sure

Sleep apnea*

Yes

Not Sure

Thyroid problems*

Yes

Not Sure

Kidney problems*

Yes

Not Sure

Diabetes*

Yes

Not Sure

Stroke*

Yes

Not Sure

High/ low blood pressure*

Yes

Not Sure

High cholesterol*

Yes

Not Sure

Congenital heart defect*

Yes

Not Sure

Heart murmur*

Yes

Not Sure

Heart surgery*

Yes

Not Sure

Heart attack/Angina*

Yes

Not Sure

Pacemaker*

Yes

Not Sure

Swollen ankles, feet, or hands*

Yes

Not Sure

Rheumatic fever*

Yes

Not Sure

Artificial valves*

Yes

Not Sure

Pre-medication with antibiotics for dental treatment*

Yes

Not Sure

BP:

HR:

Others, Please Explain:

Are you taking any prescription / over the counter drugs or herbal supplements?*

Yes

Please list them:

Please select your allergy(ies):

Please Specify:

Women Only:

Are you taking any birth Control Pills?

Yes

Are you Pregnant?

Yes

Number of months?

Consent and 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 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.

Date*

Signature:*