New Patient Form – Teulon Dental Centre

Title

Name *

First

Last

Health Card Number *

Email Address

Date of Birth *

Occupation

Employer

Referred By

Address *

Postal Code *

Home Phone Number

Work Phone Number

Mobile

Emergency Contact Name

Emergency Contact Phone Number

Are You being treated for any medical condition at the time or have been treated within the last year?

YES
NO
NOT SURE

If YES, Why?

When was your last medical check-up?

Have there been any changes in your general health in the last year?

YES
NO
NOT SURE

If YES, please explain

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

YES
NO
NOT SURE

If YES, please list

Do you have any allergies? If you answered YES, please list using the categories below:

YES
NO
NOT SURE

Medications

Latex/Rubber Products

Other (e.g. Hay Fever, Foods)

Have you ever had an uncommon or adverse reaction to any medication or injections?

YES
NO
NOT SURE

If YES, please explain

Do you have or have you ever had asthma?

YES
NO
NOT SURE

Do you have or have you ever had any heart or blood pressure problems?

YES
NO
NOT SURE

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (infective endocarditis) a heart condition from birth (i.e. congenital heart disease) or a heart implant?

YES
NO
NOT SURE

Have you ever had hepatitis, jaundice or liver disease?

YES
NO
NOT SURE

If YES, please explain

Do you have a prosthetic or an artificial joint ?

YES
NO
NOT SURE

If YES, please explain

Do you have a bleeding problem or a bleeding disorder?

YES
NO
NOT SURE

If YES, please explain

Have you ever been hospitalized for any illness or operation?

YES
NO
NOT SURE

If YES, please explain

Do you have any condentions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

YES
NO
NOT SURE

If YES, please explain

Please Select All Applies

Are there any conditions or diseases not listed above that you have or have had?

YES
NO
NOT SURE

If YES, please explain

Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)

YES
NO
NOT SURE

If YES, please explain

Do you smoke or chew tobacco products?

YES
NO
NOT SURE

If YES, What do you use?

How often?

Have you tried to quit?

Are you nervous during dental treatment?

YES
NO
NOT SURE

Are you Pregnant?

YES
NO
NOT SURE

Who is your family physician?

Do you have Dental insurance?

YES
NO

If YES, What company, policy Number and ID Number?

Previous Dentist

Phone Number

PHIA *

PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organization. We Do this for the purposes such as; To provide you with health care; To get payment for your care which could include private insurers; To do health system planning and research; To report as required by law; Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.

Release *

I authorized release; to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of service described to the named dentists Dr. Baher Botros OR/AND Dr. Mary Mikhaeil

Claims *

I hereby assign my benefits, payable from claims submitted electronically to Dr. Baher Botros OR/AND Dr. Mary Mikhaeil