Solace Dental Care

Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us: we will be happy to help.

PERSONAL INFORMATION Date ________/________/_________.

Name_________________________________________________ Date of Birth _______________________ Age _________________

Address_______________________________________________ City/Prov/Postal Code _______________________________________

¨Male ¨Female ¨Single ¨Married ¨Other Employer _________________________________________

Referred by: ____________________________________

CONTACT INFORMATION

Spouse’s Name ____________________________________ Spouse’s Date of Birth ____/____/____ Spouse’s Phone #___________________

Home Phone# (____)_____________________ Cell Phone# (____)________________Work Phone# (___)___________________ Ext# _______

Email Address ____________________________________________

In the event of an emergency, whom should we contact? Name______________________________ Relationship _________________________

INSURANCE INFORMATION

Work Phone# ________________________ Home Phone# _____________________ Cell Phone# ______________________________

VERIFICATION AND AUTHORIZATION

DO YOU HAVE INSURANCE COVERAGE? ¨ Yes ¨ No. If yes, please give information to the receptionist.

I certify that I have read and understood the above information to the best of my knowledge. I certify that I have accurately answered the questions on the new patient registration forms. I understand that providing incorrect information can be dangerous to my health. I authorize Solace Dental Care to obtain previous medical/dental records from physicians and dentists. I also authorize Solace Dental Care to release diagnosis and treatment information to physicians, dentists, and to my insurance company. I understand that Solace Dental Care does not accept assignment of insurance, and that I am responsible for payment of all services rendered on my behalf.

Signature________________________________________________________ Date _______/_______/_______.

DENTAL HEALTH HISTORY

Are you aware of clenching, grinding or bruxing your teeth?....................... ¨ Yes¨ No Do you have any loose teeth? ……. ..¨ Yes ¨ No

Does your jaw make noises, can’t open properly, or cause pain or discomfort? ¨ Yes¨ No Do you have toothaches? …….…….…¨ Yes ¨ No

Does your jaw get stuck so that you can’t open properly?........................... ¨ Yes ¨ No Do you gag easily? ………….……..... ¨ Yes ¨ No

Have you ever worn a mouth splint or night guard? .................................... ¨ Yes ¨ No Have you had orthodontic treatment?…¨ Yes¨ No

Do you chew on only one side of your mouth? If Yes. Why?...................... ¨ Yes ¨ No Do you have difficulty chewing food? .¨ Yes ¨ No

Do you have sensitive teeth to hot, cold or sweet? (Circle)......................... ¨ Yes ¨ No Do you know of any teeth cavities? ¨ Yes ¨ No

Are you satisfied with the appearance of your smile? ................................. ¨ Yes ¨ No Do you wear full or partial dentures? .¨ Yes ¨ No

Is it important for you to keep your teeth? …………………………………… ¨ Yes ¨ No Have you ever had crowns/Bridges …¨ Yes ¨ No

Have you ever had a complication with dental treatment? If yes explain: ……¨ Yes ¨ No Does food catch between your teeth?..¨ Yes ¨ No

________________________________________________________________________

Are you apprehensive about dental treatment? If yes. Why? ¨ Yes ¨ No _______________________________________________________

DENTAL HYGIENE HISTORY

Do your gums bleed easily when you brush or floss? ………………………………………….......... ¨ Yes ……. .............. ¨ No

Do your gums feel swollen or tender? .............................................................................................................. ¨ Yes ........................... ¨ No

Have you ever been treated for periodontal disease? ........................................................................................ ¨ Yes ........................... ¨ No

Have you received oral hygiene instructions regarding the care of your teeth and gums? ................................. ¨ Yes ........................... ¨ No

How often do you brush your teeth? ______________ ____________________ How often do you floss? _____________________________

How often do you visit the dentist? ¨ 3months, ¨ 6 months, ¨ yearly. Date of your last dental exam: _________________________

What is your primary reason for seeking dental treatment now (chief complaint)? ___________________________________________________

MEDICAL HISTORY

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY.

Chest Pain (Angina)................................................................. ¨

Shortness of breath.............................................................. ¨

Blood pressure high or low....................................................... ¨

Heart murmur.......................................................................... ¨

Mitral valve prolapse............................................................... ¨

Rheumatic fever....................................................................... ¨

Pacemaker............................................................................... ¨

Artificial heart valve................................................................ ¨

Heart attack............................................................................. ¨

Swollen Ankles......................................................................... ¨

Easy bruising............................................................................ ¨

Frequent nose bleeds................................................................. ¨

Abnormal bleeding................................................................... ¨

Blood disease (anemia)............................................................. ¨

Leukemia................................................................................. ¨

Arthritis................................................................................... ¨

Back or neck pain................................................................. ¨

Joint replacement (total hip, knee).......................................... ¨

Fainting spells, seizures, or epilepsy......................................... ¨

Stroke...................................................................................... ¨

Diabetes ……..……………………….……..Type I ¨ Type II ¨

Insulin dependent..................................................................... ¨

Tuberculosis or other respiratory disease.................................. ¨

Asthma.................................................................................... ¨

Herpes¨ HIV- Positive¨ AIDS¨

Glaucoma................................................................................. ¨

Kidney Disease......................................................................... ¨

Liver Disease........................................................................... ¨

Thyroid/Parathyroid disorder................................................... ¨

Family history of periodontal disease....................................... ¨

Hepatitis A/B/C........................................................................ ¨

Allergy

Do you have allergies? ¨ Yes ¨ No

If yes to what _____________________________

Are you allergic or have you reacted adversely to any of the following?

Latex ..................................................................................... ¨

Dental anesthetics or epinephrine............................................ ¨

Penicillin................................................................................. ¨

Sulfa Drugs............................................................................... ¨

Barbiturates, sedatives or sleeping pills..................................... ¨

Aspirin or Ibuprofen................................................................ ¨

Codeine.................................................................................... ¨

Women

Are you taking contraceptives or hormones?........................... ¨

Are you pregnant?................................................................... ¨

Are you nursing?...................................................................... ¨

Do you smoke or chew tobacco? ¨ Yes ¨ No

If yes, how much? ______________________________________

Do you have emphysema? ¨ Yes ¨ No

Are you presently receiving medical care? ¨ Yes ¨ No

If yes, what for: ___________________________________________

________________________________________________________

Have you had any major surgeries? ¨ Yes ¨ No

If yes, list dates: ___________________________________________

________________________________________________________

Physician’s Name: _________________________________________

City and phone #: ________________________________________

Pharmacy Name and phone #: _______________________________

Do you have any disease or medical condition not listed above? ________________________________________________________________

Do you require Pre-medication before dental treatments? ¨ Yes ¨ No

Have you ever taken medication for weight management (i.e Fen-Phen)? __________________________________________________________

Please list any medication, supplements or natural remedies you are taking: _______________________________________________________

_____________________________________________________________________________________________________________________

Which of the following are you taking or have taken in the last 12 Months?

Anticoagulants (e.g. Coumadin, Plavex)............................... ¨........... Nitroglycerin ……………………………………………………… ¨

Cortisone (steroids) ........................................................ ¨........... Aspirin …………………………………………………………….. ¨

Anti-inflammatory drugs.......................................................... ¨........... Codeine……………………………………………………………. ¨

High blood pressure medication......................................... ¨........... Antibiotics or sulfa drugs………………………………………….. ¨

Tranquilizers or antidepressants....................................... ¨........... Insulin, Orinase or similar drugs…………………………………… ¨

Digitalis or any heart medication...................................... ¨

I HAVE READ MY MEDICAL HISTORY AND CONFIRM THAT IT STATES MY PAST AND PRESENT CONDITIONS.

Date: ________/_______/_______ ______________________________________ _______________________________________

DD MM YYYY Patient Signature Reviewed – Clinic Member (Initial)

Date: ________/_______/_______ ______________________________________ _______________________________________

DD MM YYYY Patient Signature Reviewed – Clinic Member (Initial)

Date: ________/_______/_______ ______________________________________ _______________________________________

DD MM YYYY Patient Signature Reviewed – Clinic Member (Initial)

Date: ________/_______/_______ ______________________________________ _______________________________________

DD MM YYYY Patient Signature Reviewed – Clinic Member (Initial)

Date: ________/_______/_______ ______________________________________ _______________________________________

DD MM YYYY Patient Signature Reviewed – Clinic Member (Initial)