New Patient Form

TOOTH WORKS DENTISTRY

Tooth Works Dentistry would like to welcome you to our dental practice.

In your new patient exam, we will examine your teeth, gum tissue, the function of your jaw joint, obtain a digital scan of your teeth and perform an oral cancer screen. Together we will discuss our findings and develop a treatment plan.

We are happy to help you submit dental claims to your insurance. If dental claims do not specify amount payable to our practice on day of treatment, you will be responsible for the payment. We accept Visa, MasterCard, American Express, Debit.

Please fill out and submit the form below with your personal information/medical history and consent form. If you have dental benefits, please bring your coverage information with you and to this initial visit as well.

Step 1 of 3 - Personal Information

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Personal Information Consent Form

We are committed to protecting the privacy of your personal information and to using it in a responsible and professional manner.

Personal information is used to open and update patient files, to contact patients for follow-up treatment and to process dental benefit claims. We also contact patients about relevant changes or updates within our practice.

Financial information is used to process payments for our services, to process claims for third party providers/dental insurance companies and collect unpaid accounts.

Medical and dental information is used to diagnose and treat dental conditions, safely and appropriately.

Untitled(Required)

I, certify that I have provided an accurate and complete personal and medical – dental history and have not knowingly omitted any information.

Untitled(Required)

I authorize the dentist to perform diagnostic procedures and treatments as may be necessary for my dental care.

Untitled(Required)

I also understand that consultation with my medical doctor may be required and I consent to my physician being contacted if necessary.

Untitled(Required)

I consent to photographs being taken during the course of my treatment.

Untitled(Required)

I consent that in the event of a needle stick injury to our staff during your dental treatment, that I will submit to a laboratory blood test to screen for any blood-borne communicable diseases.

Billing Procedures

Our office offers assignment of benefits for your insurance carrier(s). If your insurance does not respond, those benefits will be assigned to the patient. Services will be paid in full for each visit.

We will prepare all necessary reports to help collect any benefit from your insurance. Our fees are not based on the insurance company fee guides.

Due to the high demand in prime appointments, we require a minimum of 2 business days notice to cancel or reschedule. If insufficient notice is given, a fee of $100/hr booked, will be charged.

I consent to the billing procedures above, as well as the collection, use and disclosure of my personal information as indicated below.

Date

DD slash MM slash YYYY

Name(Required)

Signature(Required)

Personal Information

Your Name(Required)

First Name Last Name Preferred

Preferred Pronoun(Required)

Date of Birth (DD/MM/YYYY)(Required)

DD slash MM slash YYYY

Occupation(Required)

Address(Required)

Street Address Province Postal Code

Phone Number (H)(Required)

(Cell)(Required)

(Other)

Email address(Required)

In Case of Emergency(Required)

Relationship(Required)

Phone(Required)

How did you hear about us?(Required)

Do you have dental insurance?(Required)

Yes

Insurance Information

Primary Insurance

Company Name(Required)

Insurance Holder Name(Required)

Date of Birth (DD/MM/YY)(Required)

DD slash MM slash YYYY

Policy/Group #(Required)

I.D./Certificate #(Required)

Secondary Insurance

Company Name

Insurance Holder Name

Date of Birth (DD/MM/YY)

DD slash MM slash YYYY

Policy/Group #

I.D./Certificate #

MEDICAL HISTORY QUESTIONNAIRE

The following information is required to enable us to provide you with the best possible dental care. All information is confidential. Please fill in the entire form.

1. Are you currently being treated for any medical condition?(Required)

Yes

Please specify:(Required)

2. When was your last medical check-up?(Required)

DD slash MM slash YYYY

3. Have you been hospitalized recently?(Required)

Yes

If so, for what condition?(Required)

4. Physician Name(Required)

Contact(Required)

5. Are you taking any medications, non-prescription drugs or herbal supplements? If yes please list.(Required)

Yes

Please specify(Required)

Drug Name

Reason

Dosage

6. Do you have any allergies?(Required)

Yes

Please check.(Required)

Please check.

Medications

Latex

Anesthetics

Other (e.g. hay fever, foods)

Which ones?(Required)

7. Have you ever had any unusual reactions to local anesthesia (freezing) or medications?(Required)

Yes

8. Do you have asthma or do you use an inhaler daily?(Required)

Yes

9. Do you have or have you ever had any heart or blood pressure problems?(Required)

Yes

10. Do you have any joint replacements?(Required)

Yes

11. Do you require premedication prior to dental treatment?(Required)

Yes

12. Do you have any conditions or therapies that could affect your immune system?(Required)

(e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy).

Yes

Please specify:(Required)

13. Have you ever had hepatitis, jaundice, or liver disease?(Required)

Yes

14. Do you bruise easily or bleed abnormally?(Required)

Yes

15. Do you have or have ever had any of the following?(Required)

Yes

Please check.(Required)

Please check.

Chest pain/angina

Heart attack

Lung Disease

Kidney Disease

Cancer

Osteoporosis

Thyroid Disease

Cold Sores

Tuberculosis

Artificial Heart Valve

Pacemaker

Blood Disorder

Steroid Therapy

Diabetes (Type 1/Type2)

Stomach Problems

Hearing Impairments/Aids

Seizures (epilepsy)

Stroke

High Blood Pressure

Iron Deficiency

Arthritis

Mental Health Problems

Shortness of Breath

16. Are there any conditions or diseases not listed above that you have or have had?(Required)

Yes

Please explain.(Required)

17. Do you have a family history of any diseases or medical conditions?(Required)

Yes

Please specify:(Required)

18. Do you use tobacco products?(Required)

Yes

If yes are you interested in quitting?(Required)

Yes

19. Do you use marijuana or recreational drugs?(Required)

Yes

20. Are you nervous during dental treatment?(Required)

Yes

21. Are you pregnant or breast-feeding?(Required)

Yes

(Required)

Pregnant

Breastfeeding

If pregnant, which week?(Required)

DENTAL QUESTIONNAIRE

1. Would you like to improve your smile?(Required)

Yes

2. Would you like to improve the alignment of your teeth?(Required)

Yes

3. Do you have any missing teeth that you would like replaced?(Required)

Yes

4. Do you wear dentures?(Required)

Yes

5. Do you have any dental implants?(Required)

Yes

6. Do you currently experience any pain or sensitivity with your teeth?(Required)

Yes

7. Do your gums bleed when you brush and floss?(Required)

Yes

8. Are you aware of teeth clenching/grinding, cheek/nail biting, lip biting or mouth breathing?(Required)

Yes

9. Do you have a night guard (splint)?(Required)

Yes

10. Do you use a CPAP machine or snore appliance?(Required)

Yes

11. Do you have any jaw (TMJ) problems?(Required)

Yes

12. What concerns you most about your dental health?(Required)

To the best of my knowledge, the above information is correct.(Required)

Patient/Parent/Guardian Signature

Date(Required)

DD slash MM slash YYYY

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Comments

This field is for validation purposes and should be left unchanged.

TOOTH WORKS DENTISTRY

New Patient Form

Tooth Works Dentistry would like to welcome you to our dental practice.

Personal Information Consent Form

Billing Procedures

Personal Information

Insurance Information

Primary Insurance

Secondary Insurance

MEDICAL HISTORY QUESTIONNAIRE

DENTAL QUESTIONNAIRE

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