New Patient Form — MY Prosthodontic Dental Clinic

Step 1 of 5

Patient Information

Please fill in your personal details.

Name

Last name *

First name *

Middle initial

Preferred name

Personal details

Date of birth *

Title

Gender

Male Female Other / Prefer not to say

Family status

Married Single Child Other

Contact

Email address *

Mobile / Cell *

Home phone

Work phone

Extension

Address

Street address

City

Province

Postal code

Referral

Who referred you to our office?

Step 2 of 5

Medical History

This helps us provide the safest care possible. All information is confidential.

General health

Are you experiencing pain or discomfort?

Has your general health changed in the past year?

Are you under the care of a physician?

Hospitalized or had a serious illness in the last 5 years?

Do you have or have you had any of the following? (check all that apply)

Medications & allergies

Are you taking any medications?

Allergic or adverse reaction to any medication?

Additional health questions

Do you stop due to chest pain when walking up stairs?

Do your ankles swell during the day?

Trouble with previous dental treatment?

Abnormal bleeding with extractions or surgery?

Any other condition we should know about?

Are you a smoker?

For women: Are you pregnant?

Expected due date

For women: Taking birth control pills?

Step 3 of 5

Dental History

Dental visits

How often do you see a dentist?

Every 6 months Yearly Other

Last dental visit

Last cleaning

Last full x-rays

How would you rate your dental health?

Excellent Good Fair Poor

Previous dental treatment

Have you had any of the following?

Do you have dental implants?

Symptoms & concerns

Sensitivity to:

Cold Sweets Heat Other

Gums bleed when:

Brushing Flossing Spontaneously

Pain or swelling of gums?

Aware of any loose teeth?

Do you chew on only one side?

Jaw & habits

Grind or clench your teeth?

Mouth breathe while asleep?

Bite your lips or cheeks?

Hold foreign objects with teeth (pens, pins)?

Does your mouth hurt when clenched?

Does your jaw crack or pop?

Difficulty opening or closing jaw?

Pain in your ears?

Do you gag easily?

Any growths or sore spots in your mouth?

Concerned about appearance of your teeth?

Emotional concerns about dental visits

Step 4 of 5

Insurance & Emergency

Insurance information

We are a non-assignment office — your insurer reimburses you directly. We submit claims electronically on your behalf as a courtesy.

Do you have dental insurance?

Insured last name

Insured first name

Middle initial

Insurance company

Group number

Certificate / ID #

Insured's date of birth

Parent / Guardian Information

Last name

First name

MI

Date of birth

Relationship to patient

Email

Mobile / Cell

Home phone

Street address

City

Province

Postal code

Emergency contact

Name (relative, spouse, or local friend)

Street address

City

Province

Postal code

Mobile / Cell

Home phone

Step 5 of 5

Policies & Consent

Please read and confirm the following.

Financial & payment policies

Payment

All payments must be paid in full at the end of each appointment. We accept Visa, Mastercard, Debit and cash.

Insurance

MY Prosthodontic Dental Clinic is a non-assignment office — we do not accept payment directly from insurance companies. We submit claims electronically on your behalf as a courtesy. If accepted, your insurer reimburses you directly. All treatment plans are based on your dental needs, not your coverage.

Cancellation & Rescheduling

We require 2 business days notice to change or cancel an appointment. Cancellations with less than 2 business days notice are subject to a $90.00 fee.

Patient's Responsibilities

There are over 30,000 dental plan contracts in Ontario and each is different. Please familiarize yourself with your plan. MY Prosthodontic Dental Clinic is not responsible for your insurance coverage.

I have read, understand and agree to the policies above. *

General release & medical history certification

I certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I authorize the dentist to perform previously discussed diagnostic procedures and treatment as necessary. I understand that consultation with my medical doctor may be required and consent to my physician being contacted if necessary. I acknowledge responsibility for payment for dental services for myself or my dependents.

I confirm the above. *

Insurance authorization (if applicable)

I authorize release of information contained in claims submitted electronically to my dental benefits plan administrator and the CDA. I also authorize communication of information related to the coverage of services to the named dentist. This authorization continues until revoked.

I authorize the above.

Signature

Full name (acts as your electronic signature) *

Today's date *