Willowdale Dental Group - Yonge & Sheppard    Back to Forms

Patient Registration, Health History & Office Policies

25 Sheppard Ave. W., #125, North York, ON, M2N 6S6      416-226-2535

The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Patient Contact Information

Patient's Name:
E-mail:
Patient's D.O.B.
Sex:

Home Phone #:
Cell #:
Address (Inc. Apt # if applicable):
City:
Province:
Postal Code:
Person responsible for account: Self / Other
Do you have a dental plan?

Insurance Company:
Group Policy/Plan Number:
Certificate / ID #:
Preferred appointment times:
 
Employer:
Occupation:
What is the name of your previous dentist?
Family Physician:
Phone Number:
In case of an emergency please notify:
Relationship:
Telephone:
Referred by
 
 

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.

YesNo YesNo
Are you in good health? Do you bleed or bruise easily?
Have you ever had a heart murmur, mitral valve prolapse or rheumatic Fever Have you ever been advised by your doctor to take antibiotics before dental treatment?
Have you ever been exposed to Hepatitis or Jaundice? Women only: Are you pregnant or breast-feeding?
Has there been any change in your general health in the past year?

If yes, explain
Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind?

If yes, please specify
Do you have any allergies? (e.g. penicillin, latex/rubber product)

If yes, please specify
Do you have a heart problem of any kind?

If yes, please explain
Have you ever been hospitalized for any illness or operations?

If yes, please explain

Do you have or have you ever had any of the following? Please check those that apply.

YesNo YesNo
AIDS Dizziness
Anemia Epilepsy
Arthritis/Rheumatism Excessive bleeding
Asthma Fainting
Blood Disease Hay Fever
Cancer Head Injuries
Diabetes High/Low Blood Pressure
Hip Replacement Surgery Stomach Ulcer
Knee Replacement Stroke
Kidney Disease Thyroid Problem
Liver Disease Tuberculosis
Lung Disease Venereal Disease
Mental Disorder Prosthetic Heart Valve
Have you ever had any illness not included above?

If yes, please specify

Dental History

YesNo YesNo
Have you ever had a dental examination with a full series of x-rays of your teeth and jaws? Tooth pain or discomfort while chewing
Have you ever had any problems/reactions to local anaesthetic? Are your teeth sensitive to Cold?
Are your teeth sensitive to Heat? Are your teeth sensitive to Sweets?
Are your teeth sensitive to Other Things? Do your gums bleed when: Brushing?
Do your gums bleed when: Flossing? Do your gums bleed when: Spontaneously?
Does food lodge between your teeth? Does your jaw crack, pop or grate when opened widely?
Do you grind or clench your teeth?
Date of your last dental visit:

Reason for today's visit:

Examination and Cleaning?
Emergency or Specific Problem?
Other

Office Policy (Please Read)

We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to paid for at each visit as they are performed.

Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.

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