New Patient Form with Anaesthetic Consent 2026

PATIENT INFORMATION
- Title
- First Name*
- Last Name*
- Preferred Name
- Date of Birth*
  yyyy/mm/dd
- Care Card Number
- Gender
  - Male
  - Female
  - Other
- Mailing Address*
- Physical Address*
- City*
- Province*
- Postal Code*
- Country*
- Home Phone
- Cellular Phone*
- Work Phone
- Other Phone
- Email*
- Whom may we thank for referring you?
IN CASE OF EMERGENCY
Please specify who we should notify
- Name*
- 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*
- Signature*
- Date*
DENTAL HISTORY
Reason for your visit*
- Former Dentist*
- Email*
- City & Province*
- Phone*
- Date 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 HISTORY
- Family Doctor*
- Phone
- Address
- 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 type
  Blood 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 type
  Hepatitis type
- Please check the box
  - Jaundice
  - Kidney disease
  - Bladder problems
  - Cancer
  - Chemotherapy
  - Radiation therapy
  - Swollen feet or ankles
  - Special diet
Women Only
Are 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:*
- Signature*
- Date*
INFORMED CONSENT: ADMINISTRATION OF LOCAL ANAESTHETICS
There are potential complications inherent to the administration of local anaesthetics:
(i) There may be an allergic reaction to the anaesthetic.
(ii) There may be adverse medication reaction to the anaesthetic.
(iii) There may be temporary or permanent injury to nerves and/or blood vessels from the injection.
(iv) There may be inadvertent contact or penetration of a blood vessel resulting in a transient sensation of a racing heart rate and/or a warm sensation across part of the face. A hematoma or bruise may result, which will resolve on its own.
(v) The injection areas may be uncomfortable following treatment.
(vi) The jaw may be sore, stiff and/or have limited range of opening. Existing jaw joint issues may be aggravated.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of local anaesthesia and have received answers to my satisfaction. I voluntarily assume any and all possible risks.

By signing this form, I am freely giving my consent to allow and authorize the dentists and hygienist at MacKenzie Dental Centre to administer local anaesthesia as needed for my dental treatment.
Consent*
I give my consent for the administration of local anaesthetics.*
INSURANCE INFORMATION
- Subscriber
- Subscriber’s Employer
- Relationship to Patient
- Insurance Co.
- Subscriber’s Date of Birth
- Group/Policy#
- ID/Cert. #
Notes
- Subscriber
- Subscriber’s Employer
- Relationship to Patient
- Insurance Co.
- Subscriber’s Date of Birth
- Group/Policy#
- ID/Cert. #
Notes
INSURANCE 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 health care information and may disclose such information to the above named 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 I cease to be a patient at this dental practice. Terms and Conditions*
*
- I agree
- Signature
- Date
CONSENT TO RELEASE RADIOGRAPHS
Consent*
I consent for my Radiograph x-rays to be released and sent to Mackenzie Dental.*
- Full Name*
- Signature*
- Date*
PERSONAL INFORMATION POLICY
Patients have the right to access a copy of their dental records. MacKenzie Dental Centre will require the patient’s consent in writing before releasing any information or dental records to another dental office, the patient’s physician or an authorized representative. The patient will be responsible for any fees associated with acquiring their dental records from their former dental office.
Consent*
I have read the above, and I understand my responsibilities as a patient.*
- Signature*
- Date*

PATIENT INFORMATION

IN CASE OF EMERGENCY

GENERAL CONSENT

DENTAL HISTORY

MEDICAL HISTORY

INFORMED CONSENT: ADMINISTRATION OF LOCAL ANAESTHETICS

There are potential complications inherent to the administration of local anaesthetics:

INSURANCE INFORMATION

CONSENT TO RELEASE RADIOGRAPHS

PERSONAL INFORMATION POLICY