New Patient Form

Name *

First

Last

Preferred Name

Gender at birth *

Male
Female

Birthdate (MM/DD/YYYY) *

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone Number

Cell Phone Number

Work Phone Number

Is patient a minor? *

Patient's parent or guardian name if patient is a minor

Spouse's Name

How did you hear about us?

Internet/Google search
Friends or Family
Co-worker
Flyer
Promotional Events
Walked by the office
Other

If Other please write in below box

Do you have dental insurance? *

If yes, please provide reception with Employer and Policy Information Card or email to us beforehand.

Do you have an immediate dental problem? *

Describe the problem and when did it start?

Any previous problems with dental anaesthetic? *

Do your gums bleed easily? *

Are you satisfied with the appearance of your teeth? *

Do you clench or grind your teeth? *

Do you experience headaches? *

Do you favor one side to chew on? *

Do you smoke? *

If yes, how much?

Any sensitivity to: *

Heat
Cold
Sweet
Pressure
None of the above

Do any teeth feel loose? *

Do you experience any of the following items: *

Pain/Clicking in jaw
Difficulty opening
Does food catch between your teeth?
Pain in side of face
Difficulty chewing
Have you had your bite adjusted
Pain in ear
None of the above
Other

Describe:

Allergies and drug sensitivities *

Local Anaesthetic
Sulfa
Nuts
Penicillin
Aspirin
Dyes
Codeine
Latex Gloves
None of the above

Are you currently under a physician's care for ongoing treatment? *

List any medications you are currently taking

Select any of the following which you had or have at present: *

Heart disease or heart attack
Sexually transmitted disease
Artificial joints
Heart Pace Maker
Scarlet fever
Epilepsy or seizures
Stroke
Kidney disease
Hay fever / Allergies / Hives
Liver disease
Emphysema
Glaucoma
Hemophilia
Diabetes
Radiation therapy
Nervous disease
Cancer
Chemotherapy
Bleed or bruise easily
Rheumatic fever
Anemia
Cosmetic surgery
Organ transplant
Drug addiction
High blood pressure
Fainting or dizzy spells
Asthma
Hepatitis A or B
Psychiatric treatment
Arthritis
HIV or AIDS
Thyroid disease
Tuberculosis
Cortisone treatment
Lung or breathing problems
Sinus Troubles
Other major surgeries
None of the above

Emergency Contact Name *

First

Last

Contact emergency Phone Number

Family Physician Name

Family Physician Phone Number

The responsibility for payment for services provided in this office for myself or my dependants is mine, due and payable at the time services are rendered. I also understand that at a later date, IF MY INSURANCE PLAN DOES NOT COVER ANY PREVIOUSLY EXPECTED AMOUNTS, THE REMAINDER DUE IS MY SOLE REPONSIBILITY AND NOT THAT OF THE OFFICE OR DOCTOR. *

I understand and agree

CONSENT: I hereby authorizes the Doctor to perform diagnostic procedures necessary for complete diagnosis of the patient. I also authorize the Doctor to perform treatment, medication, and therapy that may be indicated. *

I understand and agree

EDI Patient Authorization: I authorize release, to my dental benefits plan administrator, information contained in claims submitted electronically. I also assign all insurance benefits to the dental office. I hereby assign my dental benefits, payable from claims submitted electronically, to Dr. Alenabi and authorize payment electronically to him. *

I understand and agree

CANCELLATION POLICY: Please be advised that the office does require 2 WORKING DAYS NOTICE OF ANY CHANGE OR CANCELLATION TO YOUR APPOINTMENTS, OR A CHARGE WILL BE MADE TO YOUR ACCOUNT. FURTHER, ANY APPOINTMENTS MISSED UNEXPECTEDLY WILL ALSO RESULT IN A CHARGE TO YOUR ACCOUNT. *

I agree

Signature *

Date *

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New Patient Form

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