Confidential Medical & Dental History First Name(Required)MiddleLast Name(Required)Preferred NameBirth Date(Required) YYYY dash MM dash DD Phone Home(Required)Phone Mobile(Required)Email(Required) Street Address(Required)City(Required)Province(Required)Postal Code(Required)What is your chief dental concern today?(Required)Occupation(Required)Whom may we thank for reffering you to our office?Within the past year, have there been any changes in your general health?(Required) Yes No What is the date (or approximate date) of your last medical exam?Date(Required) YYYY dash MM dash DD When was your last dental visit?Date(Required) YYYY dash MM dash DD Your Primary Care Physician's Name(Required)Your Primary Care Physician's AddressPCP Phone(Required)WOMEN ONLY: Are you pregnant?(Required) Yes No Please mark any of the following to indicate Yes in response to the question:Do you grind your teeth (either consciously or during sleep)?(Required) Yes No Do you currently have any dental implants, dentures, or partials?(Required) Yes No Have you ever had complications following dental treatment?(Required) Yes No Are you currently under the care of a physician due to a specific condition?(Required) Yes No Have you been hospitalized within the last 5 years due to a surgery or illness?(Required) Yes No Do you use tobacco (smoking or chewing)?(Required) Yes No Do you have Dental anxiety?(Required) Yes No Please mark any of the following to indicate Yes in response to the question: Please indicate if you have experienced or presently have any of the following:UntitledAllergy(Required) Yes No AIDS/HIV(Required) Yes No Alcohol or chemical dependency(Required) Yes No Arthritis or Rheumatism(Required) Yes No Artificial joints or valves(Required) Yes No Asthma(Required) Yes No Blood transfusion(Required) Yes No Cancer/radiotherapy/chemotherapy(Required) Yes No Contraceptive use(Required) Yes No Diabetes(Required) Yes No Eating disorders(Required) Yes No Epilepsy/seizures(Required) Yes No Fainting/dizzy spells(Required) Yes No Heart disease(Required) Yes No High/low blood pressure(Required) Yes No Hyper/hypo glycaemia(Required) Yes No Kidney disease(Required) Yes No Excess bleeding(Required) Yes No Liver disease (Hepatitis/Jaundice)(Required) Yes No Lung disease/chest pains /Stroke(Required) Yes No Tuberculosis(Required) Yes No Mental or Nervous disorder(Required) Yes No Venereal/communicable disease(Required) Yes No Stomach ulcers(Required) Yes No Sleep apnea(Required) Yes No Do you have any other health issues, conditions, disease or allergies?Are you currently taking any kind of medication? If YES, please specify:DrugReasonDrugReasonDrugReasonDo you have any other illnesses or conditions not mentioned above?If YES, please specify:Emergency Contact's Name(Required)Emergency Contact's AddressEC Phone(Required)Is there any other family you would like to be seen? If so, please list below:Relative's NameRelative's RelationshipConsent Checkbox 1(Required) I consent to have radiographic images taken for diagnostic purposes.(Required) Consent Checkbox 2(Required) To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail. (Required) Cancellation policy(Required) CANCELLATION POLICY: (Required) Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the dentist’s day that another patient could have filled. As such, we require three (3) business days' notice for any cancellations or changes to your appointment. Patients who provide less than three (3) business days' notice or miss their appointment will be charged a late cancellation fee of $150. Authorization: I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential to be hazardous to my health. I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to third-party insurance carriers, payors, and/or healthcare practitioners. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any). I understand that my dental office will submit claim forms and pre-authorization forms to my insurance on my behalf, but it is my responsibility to be aware of/update the dental office on any changes to my coverage. I acknowledge that most insurance providers will send all correspondence to me directly, and my dental office is unable to see the outcome of claims or pre-authorizations to confirm my coverage. I acknowledge that most insurance providers will send all correspondence to me directly, and my dental office is unable to see the outcome of claims or pre-authorizations to confirm my coverage. I understand that if I have concerns with my coverage, I will need to discuss this with my insurance provider directly. Who is signing?Patient's SignParent's SignGuardian's SignDate:(Required) YYYY dash MM dash DD Draw Your Signature(Required)By entering your full name, email address, and phone number, you agree with online transfer of information that will be used by Vancouver Dental Specialty Clinic for the sole purpose of returning your request to be contacted by us. Vancouver Dental Specialty Clinic takes no responsibility for web communication.
