Scarborough Dentist | Scarborough Dental Clinic | Dental Office
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Dr. Riken Patel
Dr. Christine Caulford
Dr. Jeremy Song
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Patient Registration Form
Patient Information
Surname*
First Name*
Date of Birth*
Unknown
Gender*:
M
F
other
Address*
City*
Postal Code*
Occupation*
Employer*
Address*
Phone(Res)*
Phone(Cell)*
Email*
Family Physician*
Phone(Bus)*
Date of Last Exam
Unknown
Marital Status*
Name of Parent or Guardian
Occupation
Employer
Phone(Bus)
Emergency Contact*
Relationship*
Phone*
Whom may we thank for referring you to our practice?*
Another Patient
Doctor
Hygienist
Staff
Online
Other
Other (PLease specify)
Insurance Information
Do you have dental insurance?*
Yes
No
Name of Insured*
Insured Date of Birth
Unknown
Insurance Company*
Group#
ID# *
Secondary Insurance Information
Do you have secondary dental insurance?*
Yes
No
Name of Insured*
Insured Date of Birth
Unknown
Insurance Company*
Group#*
ID#*
Dental Information
When was your last dental visit?
Unknown
Doctor Name*
What was the date of your last full set of x-rays?
Unknown
How often do you brush per day?
Floss?
Other?
Do your gums bleed while brushing or flossing?
Yes
No
Do you feel any pain in any of your teeth?
Yes
No
Do you clench or grind your teeth?
Yes
No
Have you ever had any prolonged bleeding following extractions?
Yes
No
Do you wear dentures or partials?
Yes
No
If yes, date of placement?
Unknown
How nervous are you during dental treatment?(Not at all 1 - 2 - 3 - 4 - 5 - Very)
1
2
3
4
5
If you are nervous, would you like us to consider additional techniques along with "Freezing" to help?
Yes
No
What is the reason for today's visit?*
Health Information*
Are you being treated for any medical condition at present or have you have been treated in the last year?
Yes
No
Was your last check-up within the past year?
Yes
No
Do you have any allergies?
Yes
No
PLease specify
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Yes
No
PLease specify
Do you have or have you ever had an artificial heart valve, an infection of the heart(infective endocarditis), a heart condition from birth(congenital heart disease) or a heart transplant?
Yes
No
PLease specify
Do you have any heart or blood pressure problems?
Yes
No
PLease specify
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
PLease specify
Have you ever had a joint replacement?
Yes
No
PLease specify
Have you ever been told that you need pre-medications or antibotics a dental precedure?
Yes
No
Do you have any conditions that could affect your immune system? (eg. Leukemia, AIDS, HIV infection, radiation therapy, chemotherapy)
Yes
No
PLease specify
Do you have a bleeding/brusing problem or bleeding disorder?
Yes
No
PLease specify
Have you ever been hospitalized for any illneses or operations?
Yes
No
PLease specify
Do you have a or have ever had any of the following? Please ✓ the appropriate box.*
Rheumatic Fever
Lung disease
Tuberculosis
Arthritis
Epilepsy
Angina/chest pain
Heart attack
Pacemaker
Stroke
Asthma
Stomach ulcers
Diabetes
Mitral valve prolapse
Cancer
Organ transplant
Heart murmur
Steroid therapy
Kidney disease
Osteoporosis medications(eg., Fosamax, Actonel)
Are there any conditions or diseases not listed above that you have had?*
Yes
NO
PLease specify
Are there any diseases or medical problems that run in your family? If yes, list:*
Do you smoke? If so, how much?*
WOMEN ONLY:
Are you pregnant? If yes, how far along?*
Medication*
Do you take any current medication?
Yes
No
Please list your current medications and reasons for taking them below:
Pharmacy name:
City/Prov:
Phone:*
On a scale of 1-10, how would you rate your smile?
1
2
3
4
5
6
7
8
9
10
Optimizing Your Oral Health
Here at the Scarborough Dental Group we offer a variety of services to optimize your oral health and enhance your smile,
Please check any services below that you would be interested in learning more about:
In-Office Whitening
Invisalign
Implants
Take-Home Whitening
Veneers/Crowns
Replacing missing teeth
Sleep Apnea and Snore Guards
Laughing Gas
Other
Authorization
I, the undersigned patient, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information.
I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated.
I will assume full responsibility for the fees associated with these procedures.
I agree to the privacy policies posted in the reception area and consent to the electronic sharing of infomration with my insurance company for the purposes of processing insurance claims and the determination of benefits.
I am aware that 2 business ays notice is required to change or cancel an appointment without charge:
Patient/Guaradian Signature*
Dentist Signature
Date
Unknown
