Dental PracticeOttawa Our Services New Patient Medical History Form If you’re a new patient to Constitution Dental, please complete and submit before your first appointment. How did you hear about us?*SelectPatient ReferralLives in AreaWorks in BuildingRadioSocial MediaOtherGive some Details: Patient Contact Information Patient Type* Adult Child Adult Under Guardianship Name of Guardian First Last Gender* Male Female Other patient*Name of Patient* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address City*Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonZip Code*country*Select CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-bissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyamaricaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States of" "Moldova, Republic ofMonaco" "MongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard and Jan MayenEswatiniSwedenSwitzerlandSyrian Arab RepublicTaiwan (ROC)TajikistanTanzania, United Republic ofThailandTimor-lesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweEmail* Primary Phone Number*Cell Phone NumberWork Phone NumberBest way to contact you:* Primary Phone Number Cell Work Family Physician*Specialist NameEmergency Contact*Emergency Contact Phone Number*Insurance InformationPrimary Insurance CompanyInsurance Policy Holder* Self Spouse Parent/Guardian None of the Above Insurance Company NameName of Insurance Policy HolderPolicy Holder Date of BirthGroup Policy/Plan NumberID/Certificate NumberSecondary Insurance Company InformationInsurance Policy Holder Self Spouse Parent/Guardian Other insurance policyInsurance Company NameName of Insurance Policy HolderPolicy Holder Date of BirthGroup Policy/Plan NumberID/Certificate NumberFinancial InformationPerson responsible for account* Self Spouse Parent/Guardian Other responsibale for account*Name of Guardian First Last Preferred Method of Payment* Interact Visa Cash Mastercard Dental HistoryDate of your last dental exam MM slash DD slash YYYY Date of your last dental cleaning MM slash DD slash YYYY Date of your last dental xrays MM slash DD slash YYYY Please check any of the following problems that may apply to you.* Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing Headaches, earaches or neck pain Jaw joint pain (clicking/cracking) Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, chipped or shifting teeth Bad breath or bad taste in your mouth None of the above Do you have, or have you had any of the following?* Dentures Orthodontics Partial dentures Periodontal (gum) treatments None of the above If you could change your smile, you would….* Make your teeth brighter Make your teeth straighter Close gaps between teeth Replace metal fillings with natural tooth coloured fillings Repair chipped teeth Replace missing teeth Replace old crowns that don’t match Have a smile makeover None of the above How important is your dental health to you?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhere would you rate your current dental health?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest ratingWhy are you leaving your previous Dentist?What, if anything, in the past has kept you from having dental treatment?What is the most important thing about your future smile and dental health?What is most important thing to you about your upcoming visit?Medical HistoryThe 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 in the entire form.Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Explain Further DetailsHas there been any change in your general health in the past year?* Yes No Please Explain Further DetailsAre you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Explain Further DetailsDo you have any allergies?* Yes No Please List allergies DetailsHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Explain Further DetailsDo you have or have you ever had asthma?* Yes No Do you have or have you ever had any heart or blood pressure problems?* Yes No Please Explain Further DetailsDo you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Please Explain Further DetailsDo you have a prosthetic or artificial joint?* Yes No Please Explain Further DetailsDo you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Explain Further DetailsHave you ever been hospitalized for any illnesses or operations?** Yes No ever been hospitalized*Do you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack "mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) None of the above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Explain Further Details*Do you smoke or use other nicotine products?* Yes No Are you breastfeeding or pregnant?* Yes No Please Explain Further Details:Do you have a disability?* Yes No Please Explain Further DetailsGeneral ReleaseI agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.* I agree I do not agree I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.*Signature*Use your mouse or finger to draw your signature aboveDate DD slash MM slash YYYY
