Name Last     Name First      Usually Called

Address      City      Postal Code

Telephone Home      Business      Local/Ext

Birthdate Day      Month      Year     Social Insurance Number

Occupation      Employer

How did you find out about our office?

Phone Book     Sign      Website      Referred      Other

If referred, whom may we thank?

We would be happy to bill your insurance company directly for their portion of your dental treatment, provided we have the following information. PLEASE NOTE THAT THE POLICY IS BETWEEN YOU AND YOUR INSURANCE COMPANY, AND THAT YOU WILL BE RESPONSIBLE FOR PAYMENT OF ANY ACCOUNTS NOT PAID. YOU ARE ALSO RESPONSIBLE FOR YOUR PERCENTAGE OR DEDUCTIBLE AT THE TIME OF YOUR APPOINTMENT.

Name of Insurance Company      Insureds' Name

Policy Holder (Employer)          Insureds' Birthday Day      Month      Year`

Group Policy/Plan No    ACC/DIV(if applicable)

Insured's Certificate ID No     Deductible     Limits

Coverage: A (Basic)%       B (Dentures)%      C (Crown & Bridge)%     D (Ortho)%

Dependent Number Do your claim forms go to your employer?

How do you wish to pay for your dental services?

Cash      Debit Card      Visa     Mastercard     American Express

Payment is due at the time of the appointment unless other arrangements have been made.

Dental History

How long since your last dental visit?

Have you ever had a bad reaction to a dental anaesthetic?

Are you presently wearing partial dentures or full dentures?

If yes, how old are they?

What is your present complaint (if any)?

The data on this confidential questionnaire is essential to render the best professional care. We appreciate your cooperation on filling it out carefully so that we will have accurate records.

Medical History

Family Physician Phone Number

Are you presently under the care of a physician?

If yes, please explain

Have you had a medical examination in the last year?

Have you ever been hospitalized or had surgery?

If yes, please explain

Do you use medicine now? (Please list)

Have you ever had any of the following diseases? (Please check)

Hepatitis      Jaundice      Diabetes      High or Low Blood Pressure      Tuberculosis      Any lung disease      Venereal disease      Heart attack Heart murmur or heart disease      Stroke      Epilepsy      Cancer      Kidney disease      Mental or nervous disease      Arthritis      Rheumatic fever Stomach problems      Allergies      AIDS         None of the above

Have you ever experienced any unusual reaction to any of the following drugs? (Please check)

Aspirin     Penicillin      Codeine      Iodine      Sulfonamide(sulpha)      Barbituates (sleeping pills)      Local Anaesthesia or other medicine      None of the above

Do you bruise easily or bleed abnormally?

Do you have any prosthetic implants or joints? i.e. knee, hip,

Are you HIV POSITIVE? Have you ever been tested?

Have you ever had any injury, surgery or X-ray therapy to your face or jaws? If yes, please explain

Do you have any disease, condition or problem not listed above that you think the doctor should know about?

WOMEN ONLY! Are you pregnant? If yes, due date

Do you take birth control medication?

DUE TO THE PRECISE NATURE OF APPOINTMENT SCHEDULING, THERE WILL BE A $40 CHARGE FOR APPOINTMENTS CANCELLED WITHOUT 24 HOURS NOTICE! I, THE UNDERSIGNED (PATIENT OR LEGALLY RESPONSIBLE PARTY), AUTHORIZE DENTAL TREATMENT TO BE RENDERED BY THE DENTIST AND HIS STAFF, AND ASSUME FINANCIAL RESPONSIBILITY.