New Patient Form PATIENT INFORMATIONTitle First Name* Last Name* Preferred Name Date of Birthyyyy/mm/dd Care Card Number Gender Male Female Other Mailing Address* Physical Address City* Province* Postal Code* Country* Home PhoneCellular PhoneWork PhoneOther PhoneEmail* Whom may we thank for referring you? IN CASE OF EMERGENCYPlease specify who we should notifyName* Contact Phone*Relationship* GENERAL CONSENT* I, the undersigned, hereby request and authorize the team at MacKenzie Dental Centre to perform the necessary dental services for me, including but not limited to radiographs and administration of local anesthetics, which are deemed advisable by Dr. Philomena Gale and/or Associate(s). Terms and Conditions* Dental HistoryReason for your visit Former Dentist Email City & Province PhoneDate of last dental visit Date of last dental radiographs How often do you brush your teeth? How often do you floss your teeth? Have you ever been in a vehicle accident or experienced any blows to your jaw? If yes, please describe. Are you are being monitored by a dental specialist? Please provide the name of the specialist and the reason. Please list anything else not mentioned above that you’d like to share with us that will help us care for you, example, gag reflex, dental anxieties, inability to recline fully, etc. MEDICAL HISTORYFamily Doctor PhoneAddress Date of last visit Please check the box for any conditions that you have now or in the past.Please check the circle for any conditions that you have now or in the past. Heart problems Heart pacemaker Artificial heart valve Heart murmur Mitral valve prolapse Congenital heart defect High blood pressure Ulcers Colitis/Gastritis Sinus trouble Asthmas Breathing difficulties Emphysema Tuberculosis (TB) Artificial joints Arthritis Tobacco use E-Cigarettes use Chemical dependency Cannabis use Blood transfusion Anemia Blood disorder Blood disorder typeBlood disorder type Please check the box Prolonged bleeding Stroke Headaches Nervousness Please check the box Psychiatric treatment Mental health counselling Diabetes Thyroid disease Cortisone treatments Venereal disease HIV/AIDS Skin rash Allergies/Hives Weight loss Alcohol dependency Rheumatic fever Epilepsy Seizures Fainting or dizzy spells Use of contact lenses Glaucoma or cataract Liver disease Hepatitis Hepatitis typeHepatitis type Please check the box Jaundice Kidney disease Bladder problems Cancer Chemotherapy Radiation therapy Swollen feet or ankles Special diet Women OnlyAre you pregnant or trying to get pregnant? Y N Due Date Are you breastfeeding? Y N Are you on birth control medications? Y N Have you had any reaction to dental or general anaesthesia? If yes, please describe. Are you being treated for any medical condition at the present or within the last year? If yes, please describe. Have you ever been advised to take antibiotics prior to dental treatment? Has there been any change in your general health in the past year? If yes, please describe. Please list any medications, supplements or vitamins that you are currently taking or are supposed to be taking. Please list any allergies or reactions to any medications or to Latex. Have you ever had an operation or been hospitalized? Please detail the circumstances and any complications. Consent* To the best of your knowledge, the above information is correct:* Insurance InformationSubscriber Subscriber’s Employer Relationship to Patient Insurance Co. Subscriber’s Date of Birth DD slash MM slash YYYY Group/Policy# ID/Cert. # NotesSubscriber Subscriber’s Employer Relationship to Patient Insurance Co. Subscriber’s Date of Birth DD slash MM slash YYYY Group/Policy# ID/Cert. # NotesINSURANCE ASSIGNMENT AND RELEASE: I certify that my dependent has dental insurance with the above named Company(ies) and assign directly to Dr. Philomena Gale Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. It is my responsibility to notify the dental office of any insurance coverage changes. I authorize the use of my signature on all insurance submissions. Dr. Philomena Gale Inc. may use my minor/child’s health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the minor/child ceases to be a patient of this dental practice. Terms and Conditions** I agree Δ
