New Patient NEW PATIENT FORMBOOK AN APPOINTMENT Patient InformationName* First Last Email* Phone*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Gender*MaleFemaleAre you a minor?NoYes(under the age of 18)Date of Birth* MM slash DD slash YYYY Parent's / Guardian's NameParent's / Guardian's Cell PhoneParent's / Guardian's Work Phone (if available)Employer Name (if any)OccupationIf available, please confirm this date and time to visit Start Fresh Dental Hygiene.* MM slash DD slash YYYY Time* : Hours Minutes AM PM AM/PM How did you hear about us?*Family PhysicianMedical SpecialistFamily / Friend / ColleagueOnline AdvertisingPrint AdvertisingGoogleYahooBingFacebookTwitterOtherIf you are referred to us, please specify their name here:If Other, please specify here:Medical Health HistoryFamily PhysicianPhysician Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Physician PhoneAre you under the care of a Medical Specialist? No Yes Name of Medical SpecialistMedical Specialist PhoneEmergency Contact's NameIn case of emergency, please contact this person. First Last Emergency Contact's PhoneDo you have or have you had any of the following?(Please check any that apply) Heart ailment or angina Heat Attack or Stroke Heart murmur, mitral valve prolapse, heart defect Rheumatic fever or rheumatic heart disease Artificial joint or valve High or low blood pressure Pacemaker Cancer or tumor Tuberculosis or other lung problems Kidney disease Hepatitis or other liver disease Blood transfusion Diabetes Epilepsy, seizures, or fainting spells Arthritis Herpes or cold sores Migraine headaches or frequent headaches Anemia or blood disorders Abnormal bleeding after extractions, surgery, or trauma Hay fever or sinus trouble Any Allergies or hives Asthma May be pregnant? No Yes Do you smoke or use chewing tobacco? No Yes Are you allergic to, or have you reacted adversely to any of the following? Latex materials Penicillin or other antibiotics Local anesthetic Metal Food Other If Other, please specify:Do you have any disease, condition, or problem not listed above that you are being treated for?Have you ever been advised to take antibiotics before dental treatment? No Yes Any change in your general health in the past year? No Yes If Yes, please specify here:Are you presently taking any Prescription or NON Prescription drugs? No Yes If Yes, please specify here:(Include herbal remedies)Additional InfoPlease add anything else you would like us to know about:Patient DeclarationI, the undersigned, certify that I have provided an accurate and complete personal, medical history and have not knowingly omitted any information. Should there be any changes in either my health or any other information I have provided, I will advise this dental hygiene office. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy. I understand that responsibility for payment of the dental hygiene services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. *The Submit button will appear after certify that the information above is accurate. Yes, I certify that the information above is true.* Subscribe to mailing listI would like to receive promotions and special offers from your company. Yes, add me to the mailing list. EmailThis field is for validation purposes and should be left unchanged.
