PATIENT REGISTRATION INFORMATION

PLEASE PRINT Mr./Mrs./Ms./Miss/Dr

First Name

Phone

BUS

Cellphone

Home Address

Apt

City

Postal Code

Age

Date of Birth

Do you have dental insurance coverage?

Referring Dentist:

Phone

Family Dentist:

Phone

Family Physician:

Phone

Emergency Contact

Relation

Phone

Medical Information ( Please circle the appropriate answer)

1. Are you presently in good health?

YES NO

2. Have you ever had a serious illness?

YES NO

3. Have you been under the care of a physician during the last 2 years?

YES NO

4. If yes, why?

5. Please circle any of the following to which you are sensitive or allergic

Other allergies (please list)

6.Have you ever had excessive bleeding?

YES NO

Any Medical Conditions?

8. Are you taking any medication (pills), including Aspirin and Herbal Supplements of any kind at this time?

YES NO

If yes, please list the names and dosages:

9. For Women only:

A thorough examination and consultation is a crucial and necessary service prior to the initiation of endodontic treatment. A fee is assessed for this treatment in accordance with the fee guide of the Ontario Dental Association whether or not endodontic treatment is performed. Payment of this fee is expected at this examination appointment.

I acknowledge full responsibility for the payment of such services for my endodontic treatment and agree to pay for them in full when the services have been rendered, unless other specific arrangements are made with the secretary. I also understand that it will be necessary for me to return to my family dentist for the permanent restoration following the endodontic treatment.

Signature