New Patient Form

    Personal Information

    Today's Date:


    Date of Birth:

    Dental Insurance:

    Insurance Card Front:
    Insurance Card Back:

    Medical History

    1. Are you in good health?

    2. Are you being treated by a physician for any illness or condition?

    3. Have you had any serious illness/operation/hospitalized?

    4. Please Specify and list all current medications:

    Have you taken any long term medications in the past? Prescription or Non-Prescription

    5. Do you have any allergic reaction to any medications? e.g. Penicillin, Codeine, Aspirin

    6. Is there any family history of any illness/disease, e.g. heart problems, diabetes, cancer

    7. Have you had any injuries to your face or jaw?

    8. Do you bleed or busied easily/prolonged bleeding?

    9. Have you had any contact with the AIDS/HIV virus?

    10. Have you had any reactions to local freezing?

    11. Women: Are you pregnant?

    12. Have you been warned against taking any medication?

    Mark if any of the following apply to you

    ArthritisAIDS/HIVAsthmaBlood DisorderCancerDiabetesHeart MurmurJoint ReplacementsOn Birth Control Pills
    EpilepsyHeart DiseaseHigh/Low Blood PressureKidney DiseaseLiver DiseaseMental/Nervous DiseaseHepatitis/JaundiceSmoke/How much?(specify in comments at the end)Gum Disease
    Lung DiseaseThyroid ProblemsTuberculosisVenereal DiseasePace MakerRheumatic FeverHeart ProsthesisHave FaintedBad Mouth Odour

    Dental History

    14.When was your last dental checkup/cleaning?

    15. Are you happy with the appearance of your smile and teeth?

    Have you ever had or experienced any of the following:

    Bad Dental ExperienceCap/Crowns/BridgeRoot CanalGum TreatmentBad BreathHeadachesFood Lodgement
    Cleaning/ScalingImplantsBracesSensitive TeethSwollen/Painful GumsLock jawAnxiety
    FillingsPartial/Full DenturesExtractionsBleeding GumsGaggingClenching/GrindingTension

    I, understand, certify that I have provided an accurate and complete personal & medical-dental history & have knowing not omitted any information. I have the opportunity to ask & receive answers regarding my medical-dental history. I authorize the dentist to perform/diagnosis procedures & treatment as may be necessary for proper dental care. I also understand that consultation with a medical doctor may be required, & consent to my physician being contacted if requires. I understand that responsibility for all payments for dental services for myself/dependants is mine, & I will assume responsibility for fees associated with these services. By signing below, I am knowingly, authorizing the assignment of benefits from my primary & (if applicable) secondary benefits coverage to Dr. Gold's Source Dental. Please click submit once, and wait until the wheel on the right of the green submit button stops spinning. Please remember that your signatures are required for the form to submit. Thanks!

    Patient's Signature:

    419 King St W #2180B

    Oshawa, ON L1J 2K5

    (905) 434-5757

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