Patient Intake Form

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 Full Name:

Preferred Name:

Patient's D.O.B.

Sex:

Address:

E-mail Address

Home Number:

Work Number:

Cell Number:

Employer / School:

Position / Occupation:

Best way to contact you?

Person to contact in case of an emergency

Phone Number:

Family Doctor:

Phone Number:

Pharmacy Name:

Phone Number:

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

Insurance Policy Holder:

Other Details

Policy Holder Phone Number (if different from above):

Employer:

Insurance Company Name:

Group Policy/Plan Number:

I.D./Certificate Number:

Insurance Information

Secondary Insurance Company Information​​​​​​​

Name of Insurance Policy Holder:

Date of Birth:

Insurance Policy Holder:

Other Details

Policy Holder Phone Number (if different from above):

Employer:

Insurance Company Name:

Group Policy/Plan Number:

I.D./Certificate Number::

Method of Payment

Referral Information

How did you hear about us? (Check all that apply)

Medical History

Have you had a medical check-up in the last year?

If yes, when?

Have you ever been hospitalized or had major operations?

If so, please explain

Are you currently under a physician’s care?

If yes, what for?

Have you ever had an unusual reaction to any medications or injections?

If yes, please describe:

Are you taking any medications, non-prescription drugs, recreational drugs, or herbal supplements?

If yes, please specify:

Do you drink, smoke, vape or chew tobacco products?

If yes, explain:

Do you require pre-medication for dental treatment?

Details

Have you ever had any organ implant or medical implants? (i.e. valves, stents, joints)

If yes, please specify:

Do you experience shortness of breath or chest pains when taking a walk or climbing stairs?

If yes, please specify:

Have you had any injury, surgery or x-ray therapy to your face or jaws?

If yes, please specify:

For Women Only:

Are you pregnant or suspect you might be?

If so, what month are you in?

Are you taking birth control pills?

Are you nursing?

Do you have or have ever had any of the following:

AIDS

Allergies, seasonal

Anemia

Arthritis

Artificial heart valve

Artificial joints

Asthma

Blood disease

Bruise easily

Cancer

Chemotherapy

Diabetes

Dizziness

HIV positive

HPV

Jaundice

Jaw joint pain

Kidney disease

Liver disease

Low blood pressure

Mitral valve prolapse

Nervousness/Depression

Pacemaker

Phen fen (1 month+)

Pregnant currently

Drug addiction

Emphysema

Excessive bleeding

Fainting

Glaucoma

Heart conditions

Heart lesions, congenital

Heart murmur

Heart surgery

Hepatitis A

Hepatitis B

Hepatitis C

High blood pressure

Respiratory problems

Rheumatic fever

Rheumatism

Scarlet fever

Seizures

Sleep apnea

Stomach problems

Stroke

Thyroid disease

Tuberculosis

Ulcers

Venereal diseases

Do you or have you ever had any other illness not listed above?

If yes, please explain:

Do you have any of the following allergies? (Check all that apply)

Dental History

What is your main priority in seeking dental treatment?

How frequently do you see your dentist?

Date of last dental visit:

Date of last hygiene visit:

Date of last dental x-ray:

Your last oral cancer screening:

How often do you brush your teeth?

How often do you floss?

Do your gums bleed easily?

Please check any of the following problems that may apply to you:

Have you had any negative experiences with dentistry?

Have you ever had trouble getting numb/frozen?

Do you have or have had any of the following?

If you could change your smile, you would...

Other dental concerns:

Privacy & Release Information

Release of Information: I authorize South Kitchener Dentistry to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history friom my physician, another dental office, insurance company.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 2 days notice, otherwise it may be necessary to charge for the time lost.

​​​​​​​Patient Release: I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

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