Waterfront Dentistry By Pauls

613-966-1225

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New Patient Medical History

PATIENT INFORMATION
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Birthday*
  

IN CASE OF EMERGENCY WE SHOULD NOTIFY

Relationship:
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The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so why?*
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3. Has there been any change in your general health in the past year?*
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
5. Do you have allergies?*
6. Have you ever had a peculiar or adverse reaction to any medicines or injections?*
7. Do you have or have you ever had asthma?*
8. Do you have or have ever had any heart or blood pressure problems?*
9. Do you have or have you ever had a heart murmur, mitral valve prolapse or rheumatic fever?*
10. Do you have a prosthetic or artifical joint?*
11. Have you ever been advised by your doctor to take antibiotics before dental treatment?*
12. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
13. Have you ever had hepatitis, jaundice or liver disease?*
14. Do you have a bleeding problem or bleeding disorder?*
15. Have you ever been hospitalized for any illness or operations?*
16.Do you have or have your ever had any of the following? Please check.
19.Do you smoke or chew tobacco products?*
20. Are you nervous during dental treatment?*
21. For women only: Are you breast-feeding or pregnant? If pregnant, what is the expected delivery date?

As we schedule a dedicated time to meet your dental needs, we ask for a 48 hour notice of cancellation, which will allow us to use that time slot
to accommodate another patient. FAILURE TO PROVIDE US WITH PROPER NOTICE WILL RESULT IN A FEE OF $50.

Another new protocol is to ESCORT YOU RIGHT INTO AND OUT OF THE OFFICE once your procedure is done. This is the reason we will need a credit card (or any payment method) on file to cover any balance owing after the insurance has paid their share. We will do our very best with your insurance company, but because of our new protocols in place, we advise that you contact your insurance company and get the proper breakdown of your benefits so that there will be no surprises.

ACKNOWLEDGEMENT: To the best of my knowledge, the information above is correct:*
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