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(877) 347 5530
smile@sunshinedentistry.ca
8763 Bayview Ave Unit 10, Richmond Hill
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Home
About
Contact
Patient Registration Form
CDCP
Services
General Dentistry
Family Dentistry
Pediatric Dentistry
Dental Fillings
Dental Checkups
Dental Cleaning
Cosmetic Dentistry
Cosmetic Dentistry
Dental Veneers
Invisalign
Teeth Whitening
Dental Treatments
Dental Bridges
Dental Bonding
Dental Crowns
Dental Extractions
Wisdom Teeth Removal
Dental Implants
Dental Sealants
Dentures
Root Canal
Sedation Dentistry
Emergency Dentistry
Gallery
Insurance
Blog
Book Appointment
Patient Registration Form
PATIENT INFORMATION
First Name
Last Name
Date of Birth
Address
City
Postal Code
Home Phone
Cell Phone
Email
Where did you hear about us?
Online Search
Family/Friend
Social Media
Newspapers/Magazines
Other
Emergency Contact Number
WORK INFORMATION
Work Phone
if this form is filled for another person write the guardian (responsible person) name below
INSURANCE INFORMATION
Primary Insured
Insurance Company
Group / Policy Number
ID / Certificate Number
If covered under spouse’s plan as secondary coverage:
Secondary Insured
Insurance Company
Group / Policy Number
ID / Certificate Number
MEDICAL HISTORY
Name of Physician
Address of Physician
Office Phone Number
Are you currently under medical treatment?
Yes
No
Reason (if yes)
Have you had an allergic or unusual reaction to any of the following?
(Leave blank if all answers are No)
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetic
Yes
No
Penicillin
Yes
No
Other
FOR WOMEN ONLY
Are you Pregnant?
Yes
No
If yes, Expected date of delivery
Have you ever been treated for any of the following?
(Leave Blank if all answers are No)
Anemia
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Murmurs
Yes
No
Hepatitis
Yes
No
Jaundice
Yes
No
Kidney Disease
Yes
No
Rheumatic Fever
Yes
No
Sinus Trouble
Yes
No
Stroke
Yes
No
Tuberculosis
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Other
Please answer all questions below:
Have you ever been treated for AIDS-related complex?
Yes
No
Details
Are you taking any medications? If so, what are they?
Yes
No
Medications
Do you have heart trouble? If so, what kind?
Yes
No
Details
Do you have high or low blood pressure? Is it controlled?
Yes
No
Details
Have you ever been required to take prophylactic antibiotics prior to dental treatment?
Yes
No
Details
Do you use tobacco products? If so, how often?
Yes
No
Details
Are you subject to fainting or dizziness? If so, how often?
Yes
No
Details
Have you ever had cancer or a tumor? If so, how was it treated?
Yes
No
Details
Have you ever had any major operations? If so, what kind?
Yes
No
Details
Have you ever been involved in a serious accident?
Yes
No
Details
Do you bruise or bleed easily?
Yes
No
Details
Have you recently had a communicable disease (i.e. Mumps, Measles, etc.)?
Yes
No
Details
Dental History
Previous Dentist
Address
Phone Number
Date of Last Visit
Are you presently in any dental pain?
What is your major dental concern at this time?
Name of Patient (or the responsible person)
Date Signed
Message
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