Studio B Dental Getting to know your better

I am

First Name:

Last Name:

Preferred Name:

Date of Birth:

Male Female

Address:

Apt/Unit#:

City:

Province:

Postal Code:

Cell Phone #:

Work #:

ext.

E-mail:

Occupation:

Position:

Do you have any insurance benefits we can help you maximize?

Yes No

Family Members at our practice:	Husband/wife:
	Children:	Name: M F - Age:
		Name: M F - Age:
		Name: M F - Age:

Friends at our practice:

Pets:

Best way to contact you:

Home Text E-mail Cell

In case of an emergency - Please notify:

Phone Number:

My Favourite:

Vacation:

Restaurant:

Music:

Sport/Team:

Movie:

Hobbies/Interests:

How did you hear about us? (Check all that apply)

Referred by:

Dentist Referral:

Lives in Area Front Sign

Internet - Keywords Typed:

Youtube Facebook

Other:

Please check any of the following problems that may apply to you.

Sensitivity (hot, cold, sweet)	Tooth pain or discomfort while chewing	Headaches, earaches, neck pain
Jaw joint pain (clicking/cracking)	Teeth or fillings breaking	Grinding or clenching teeth
Bleeding, swollen or irritated gums	Loose, tipped or shifting teeth	Bad breath or bad taste in your mouth
Loose/Poor fitting dentures	Wears dentures	Previous orthodontics or gum surgery

Please share the following dates:

Last dental cleaning:

Last oral cancer screening:

Last X-Rays:

Yes No - If you could whiten your teeth for a cost anyone could afford, would you do it?

Yes No - Have you ever smoked? If yes, how many years?
Do you currently smoke? Yes No

Yes No - Are you nervous during dental treatment?

Yes No - I would be interested in different sedation options to make my visits more relaxing?

Yes No - Do you wish to speak privately to the doctor about any problem or medical condition?

If I could improve my oral health, I would...

Make my teeth brighter	Make my teeth straighter
Close spaces	Repair chipped teeth
Replace missing teeth	Replace old crowns that don't match
Have a smile makeover	Replace black metal fillings with natural, tooth coloured fillings

One a scale of 1 (low) to 10 (high)...
How important is your dental health to you?
Where would you rate your current dental health?
How would you rate the look & feel of your smile?

Why did you leave your previous dentist?

What, if anything, has kept you from having dental treatment?

What is the most important thing to you about your smile and dental health?

What is the most important thing to you about your first visit / today's visit?

Please check any of the following that apply to you:

Do you have any of the following allergies?

Codeine

Darvon

Percodan

Latex

Local anesthetic

Penicillin

Sulpha

Other

Yes No - Have you ever had a joint replacement? If yes, when?

Yes No - Has your physician ever told you to take antibiotics prior to dental procedures?
If so, why?

Yes No - Have you ever experienced complications following a medical or dental procedure?
If yes, please describe?

Yes No - Is there anything else you think we should know regarding your medical history?
If yes, please describe?

Yes No - Are you currently under a physician's care?
If yes, what for?

Yes No - Are you taking any medications/supplements?
If yes, please specify

Medications

Name:

Reason:

Dosage:

Name:

Reason:

Dosage:

Name:

Reason:

Dosage:

Family Physician's Name:

Physician's Phone Number:

How healthy would you like your teeth to be?

The best it can be Average Don't really care

What quality of dentistry do you want us to recommend?

Ideal/The best Average Just patch it up

Privacy Information
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. I understand that I am financially responsible to the dentist for the dental services provided.

Consent for Collection, Use and Disclosure of Personal Information
I agree that Village Dental Centre has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information.
I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004.

Date:

I the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Village Dental Centre all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Please answer*: 5 + 9 =

Phone: 416.226.2000