Patient Registration Form

First Name

Last Name

Date of Birth

Address

Home Phone

Cell

Appointment Reminder Preference

Text

Phone Call

Account Statement Preference

Regular Mail

Emergency Contact Person

Phone

Family Doctor

Phone

Who can we thank for referring you to our office?

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill out the entire form.

Have you recently been under the care of a physician?

Yes

Please specify

Have you ever had a serious illness or operation?

Yes

Please specify

Are you presently taking any medication either prescribed or self administered?

Yes

Drug and Reason

Do you have any heart or circulatory problems of any kind?

Yes

Please specify

Have you ever experienced shortness of breath or chest pain from light exercise?

Yes

Are you allergic to anything?

Yes

Please specify

Have you ever had excessive bleeding that required special treatment?

Yes

Do your ankles swell during the day?

Yes

Have you ever had a peculiar or adverse reaction to any medicines or injections?

Yes

Please specify

Do you smoke or chew tobacco products?

Yes

IF yes, how many per day?....

Developmental Disability

Yes

Please specify

Mental Disorder

Yes

Please specify

Are there any conditions or diseases not listed above that you have or have had?

Yes

Please specify

Are there any diseases or medical problems that run in your family (ie. Diabetes, Cancer, Heart Disease)..

Yes

Please specify

For women only: Are you or could you be pregnant?

Yes

DENTAL HISTORY

Previous Dentist

Date of Last Check Up

How would you rate the condition of your mouth?

3 months

4 months

6 months

9 months

12 months

Not routinely

Are you nervous during dental treatment?

Yes

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes

Have you ever had braces, or orthodontic treatment?

Yes

Do you wear dentures or partials?

Yes

Have you had any teeth removed?

Yes

Is there anything about the appearance of your teeth that you would like to change?

Yes

Please specify

Have you ever whitened (bleached) your teeth?

Yes

Have you been disappointed with the appearance of previous dental work?

Yes

Do you have problems with your jaw joint (pain, clicking, locking, popping)?

Yes

Do you/would you have any problems chewing gum?

Yes

Do you favour one side when chewing?

Yes

Do you grind or clench your teeth?

Yes

Have you ever worn a bite splint while sleeping?

Yes

Do your gums bleed while brushing or flossing?

Yes

Are you aware of an unpleasant taste or odor in your mouth?

Yes

I hereby certify the above to be true to the best of my knowledge. If I ever have changes to my health or if my medications change, I will inform the dentist at my next visit

Patient/Parent Signature:

Date

Email/Text Permission

Sky Dental has my consent to contact me using text/email according to my preferences listed above.

Patient/Parent Signature:

Date

Reviewing Dentist/Signature

QUICK LINKS

About
Services
Testimonials
Patient Forms
Contact Us
Why Us

OPENING HOURS

Monday: 10:00am – 7:00pm
Tuesday: 9:00am – 5:00pm
Wednesday: 9:00am – 7:00pm
Thursday: 9:00am – 5:00pm
Friday: 9:00am – 6:00pm
Saturday: 9:00am – 3:00pm
Sunday: Closed

CONTACT US

Website Design by:

Patient Registration Form

MEDICAL HISTORY

DENTAL HISTORY

Email/Text Permission

QUICK LINKS

OPENING HOURS

CONTACT US

Book Appointment