Prefix: Dr.   Mr.   Mrs.   Miss.  
Name *:
Prefers to be called:
City: Province: Postal Code:
Home Phone *: Cell Phone:
Business Phone: Ext:
Email Address *:
Date of Birth: Age: Sex:
Marital Status: Name of Spouse:
Are other family members patients with us: Yes No Name:
Where did you hear about us: Google Internet Flyers Other:
Family Physician: Phone:
Emergency Contact: Phone:
Subscriber's Name Subscriber's Name
Employer Employer
Ins. Co. Ins. Co.
Group / Policy No. Group / Policy No.
Cert. No. / ID No. Cert. No. / ID No.
1. Is there a dental problem you would like treated immediately? If so, please detail:
2. Have you been advised to take antibiotics before a dental appointment? Yes No
3. Women only:
Are you pregnant or suspect you may be?   Yes No Expected delivery date:
Are you breast feeding?   Yes No
Birth control pills?   Yes No
4. Have you ever been hospitalized? If so, please detail for what:
5. When was your last visit to a physician? Last complete physical?
6. Are you taking any medication? If so, please detail:
7. Are you allergic to any medication? If so, please detail:
Please indicate which of the following you presently have or ever had:
Yes No A.I.D.S. Yes No Heart pacemaker
Yes No Angina Pectoris Yes No Heart rhythm disorder
Yes No Artificial heart valve Yes No Heart surgery
Yes No Artificial joints(hip, knee) Yes No Hepatitis A
Yes No Bleed or bruise easily Yes No Hepatitis B
Yes No Congenital heart lesions Yes No Hepatitis C
Yes No Cortisone/steroid Yes No H.I.V.
Yes No Diabetes type I Yes No Latex Allergies
Yes No Diabetes type II Yes No Mitral valve prolapse
Yes No Epilepsy or seizures Yes No Rheumatic fever
Yes No Frequent earaches Yes No Sickle cell disease
Yes No Heart attack Yes No Smoking
Yes No Heart disease Yes No Stroke
Yes No Heart murmur
8. Is there any other health conditions or concerns we should know about? Yes No