New Patient Form

Dental Registration and History

Contact Informations








Emergency Contact Information





Insurance Information

YesNo



Previous Dentist



Family Physician



Medical History

YesNo



YesNo

YesNo

Medicationslatex/rubber productsOther (e.g foods)No

YesNo

OsteoporosisAsthmasHigh blood pressureHeart diseaseOrgan transplantProsthetic or artificial jointHeart attackStrokeShortness of breathPacemakerLung diseaseCancerDiabetesStomach ulcersThyroid diseasedrug/alcohol dependencyHave you ever been hospitalized for any illnesses or operations? If yes please explainDo you have any conditions or therapies that could affect your immune system? (e.g chemotherapy, leukemia, AIDS, HIV infection, Radiotherapy)Covid -19 or any flu like symptomsOther (please list)No

YesNo

YesNo

YesNo

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