201 County Court Blvd, Unit 104, Brampton, ON L6W 4L2    905-450-0700    info@countycourtdentistry.com
201 County Court Blvd, Unit 104, Brampton, ON L6W 4L2
905-450-0700
info@countycourtdentistry.com
Book Appointment

Patient Information Form


Last Name
First Name
Middle Name

Address

Postal Code
Home Phone No
Business Phone No

Employed By
Occupation

Marital Status
Spouse's Name

In an Emergency, Please Notify:
Present Physician
Phone
Whom May We Thank For Referring You
Previous Dentist
Do you have Dental Insurance
Ins. Company
Why did you come to our office

It is important that I know about your dental and medical history. Many things have a direct bearing on your dental health. I will review the questionnaire and discuss it with you in detail. Information you give me is strictly confidential and will not be released to anyone without your permission.



P.D.H.
How long has it been since you last visited a dentist?
Yes    No

Did you visit him regularly?
Yes    No

Have you ever had teeth extracted?
Yes    No

Any complications?
Yes    No

Have you ever had any bad reactions to local anaesthetic?
Yes    No

How often, do you brush your teeth?
Yes    No

Do they bleed when you brush them?
Yes    No

Do you use dental floss?
Yes    No

Medical History

P.S.H.
1. Are you in good health?
Yes    No

2. Are you presently under observation or treatment(medically or dentally) for any other complaint?
Yes    No

Other complaint?

3. Are you taking any drugs, either prescibed or self administrated?
Yes    No

4. Have you noticed any recent loss of energy or reduction in exercise tolerance?
Yes    No

5. Have you noticed any recent change in appetite?
Yes    No

6. Are you on a special diet?
Yes    No

7. Has your weight been constant?
Yes    No

8. Do you have any decrease in tolerance to heat or cold? or in other words, do you sweat excessively or feel chilled when no one else does?
Yes    No

9. Do you sleep well?
Yes    No

10. Do you have any tendency to bruise easily or bleed excessively?
Yes    No

11. Do you have any allergies?
Yes    No

12. Have you ever had a reaction to a drug or been advised against it being given you again?i.e penicillin
Yes    No

13. Have you ever had a bad reaction to either a local or general anaesthetic?
Yes    No

14. Women. Are you pregnant?
Yes    No

P.M.H.
1. Did you have any unusual childhood diseases?
Yes    No

2. Do you have, or have you ever had?
Heart Murmur
High Blood Pressure
Kidney Trouble
Liver Trouble
Psychiatric Rx
High Risk mitral valve prolapse
Epilepsy
Thyroid trouble
Tuberculosis
Asthma
Venereal disease
Blood Disorder
leukemia
Anaemia
Pace maker
Prosthetic heart valve
HIV Virus
diabetes
Sickle cell anaemia
Multiple myeloma
Prosthetic joint
3. Have you ever been hospitalized?
Yes    No

4. Have you ever had rheumatic fever?
Yes    No

5. Have you ever had hepatitis?
Yes    No

6. Have you ever taken steroids?
Yes    No

7. Have you ever had cardiac surgery?
Yes    No

8. Have you ever had any other serious illness?
Yes    No

Please Specify

Office policy

Your appointment time will be reserved especially for you. If you are unable to keep this appointment. We will require 24 hours notice. Otherwise it may be necessary to change for time lost. Office policy is that services rendered in this office are the financial responsibility of the patient. We cannot accept direct payment from your insurance company, although we will be pleased to fill out the necessary forms so that you may be properly reimbursed. Please discuss arrangements for payment with the doctor or receptionist.

Patient(Guardian) Consent & Approval

I, the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information and consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic and nitrous oxide as indicated. I will assume responsibility for fees associated with these procedures.

Patient Name
Date
Parent/Guardian
Date



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Address : 201 County Court Blvd, Unit 104, Brampton, ON L6W 4L2

Phone : 905-450-0700

Email : info@countycourtdentistry.com

   

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