NEW PATIENT REGISTRATION

New patients are kindly asked to fill out our confidential online patient registration form before their first visit. Your dental and medical history are essential to determine the course of your treatment and help us provide you with optimum dental care.

 

Patient Information
Title: First Name: Last Name:
Date of Birth: / / (mm/dd/yyyy)
Street Address: City: Postal Code:
Home Phone:
Bus. Phone: Email: Occupation:
Cell Phone: Confirm Email: Employer:

Insurance Information
Primary Policy Holder Name: Birthdate: / / (mm/dd/yyyy)
Insurance Company Name:     Policy/Group#: ID#:

Secondary Policy Holder: Birthdate: / / (mm/dd/yyyy)
Insurance Company Name: Policy/Group#: ID#:

Name of Spouse/Parent:     Phone:
Name of Family Doctor:     Phone:

Dental History
Have you ever had an unfavourable reaction after a dental treatment? Yes No
If yes, explain:
Are you currently in pain? Yes No
Main Complaint:
Are any of your teeth sensitive to the following?
If other, explain:

Health History
Have you ever had excessive bleeding requiring special treatment? Yes No
Do you wear contact lenses? Yes No
Female patients, are you or could you be pregnant or nursing? Yes No
If pregnant, which month?

Check any of the following that you have or had in the past:







Do you have any other medical problems not listed here? Specify below:

Please list any allergies to medications:

Please list medications you are currently taking:


                         

 

  • County Dental Care
  • 9 Chapel Street, Picton, Ontario
  • 613-476-2353
  • www.countydentalcare.com
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