New Patient Form Additional Adult Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply. Name of Person on the original form* Name of Patient* Birth Date* Select a Choice* MaleFemale Marital Status* ---MarriedSingleOther Work Phone Cell Phone Email* Employer* Spouses Name* University/College Student* Full TimePart Timen/a Person to Contact in Case of Emergency* Relationship to Patient* Phone Number How would you prefer your appointment reminders?* Via MailPhone CallText Message Do you have insurance?* NoYes Do you have secondary insurance?* NoYes Are you dissatisfied with the appearance of your smile?* YesNo Do you have? (please check the following that apply): * Chipped teethProtruding teethCrowded teethMisshapen teethTeeth with spaces or have gapsTeeth with old fillings or dental worknone If you could change one thing about your smile, what would it be? * What is your primary reason for booking the appointment is today? * Have you had a negative experience, or is there something you would like us to know that will help us make your visit more comfortable?* Patient Medical History Physician* Physician's Office Phone Are you currently under any medical treatment?* NoYes Have you been admitted to a hospital or needed emergency care during the past two years?* NoYes Are you currently taking any medications, including over the counter medications?* NoYes Have you ever had any complications following dental treatment?* NoYes Do you have or have had any of the following? Please check all that apply.* AIDS/HIVAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzienessEpilepsyExcessive BleedingFaintingGlaucomaHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureKidney DiseaseLiver DiseaseMental DisordersPacemakerRadiation TherapyRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrockTuberculosisTumorsVenereal DiseaseSmokerNone Are you pregnant?* NoYes Do you have any allergies to medications?* NoYes Patient Dental History Check All That Apply* Gums bleed while you brushYour teeth are sensitive to hot or cold liquid/foodsYou feel pain in any of your teethHave any sores/lumps in your mouthHave any head, neck or jaw injuriesEver experience any clicking or pain in the TMJ area, difficulty opening or closingHave frequent headachesYou clench or grind your teethYou bite your lips or cheeks frequentlyHad any difficult extractions or prolonged bleeding from it in the pastHad any orthodontic treatmentsYou wear dentures or partialsNone upload a photo We need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive. I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that Beacon Smiles Dental can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.* I have read the above conditions of treatment and payment and agree to their content.
