Patient Referral

First Name

Last Name

Email

Phone Number

Date of Birth

How did you hear about us?
Drive or Walk ByGoogle SearchNews or PublicationReferralSocial MediaOther

Emergency Contact Name

Emergency Phone Number

Emergency Relationship
SpouseChildOther Family MemberFriendOther

Street Address

Unit

City

Province

Postal Code

Country

Do you have dental insurance?
YesNoUnsure
If yes, please complete the following questions. If no, move onto Medical History

Insurance Company Name

Certificate / ID Number

Policy Number

Family Physician Name

Family Physician Number

Date of last doctor visit

Previous Dentist Name

Previous Dentist Number

Date of last dental visit

Have you had dental x-rays taken within the last 2 years?
YesNoUnsure

Do you have any of the following illnesses
Heart diseaseHigh blood pressureLow blood pressureHepatitis A/B/CDrug addictionCold soresOral cancerHave had radiation or chemotherapyHIV or AIDSOther sexually transmitted diseaseEpilepsy or seizuresTuberculosisDiabetesStrokeJaundiceAsthmaSinus troubleSnoringThyroid disorderArthritisDigestive disorderKidney diseaseGastrointestinal disorderBleeding disorder or bruise easily

Do you have any of the following conditions
Facial muscle tendernessJaw joint clicking, popping, or lockingMigraines or headachesEarachesTMJ (jaw pain)Neck or shoulder painHearing lossLumps or sores in your mouthTeeth grindingSore or tender gumsSnoringBurning sensation on your lips or tongueSleep apneaDry mouthDo you smoke

Do you suffer from any illness or condition not listed? (please list)

Are you allergic to latex?
YesNoUnsure

Are you allergic to metals?
YesNoUnsure

Are you allergic to acrylic?
YesNoUnsure

Please list all medications you are currently taking

Please list all major injuries and surgeries in the last 10 years