DENTAL SQUARE

    Welcome to our office! To assist us in serving you, please complete the following confidential information.

    PATIENT INFORMATION

    Use this form to screen patients before their appointment and when they arrive for their appointment

    Patient Last name

    First name

    Sex

    Birth Date

    Home Phone

    Cell Phone

    E-Mail

    Address

    City

    Prov.

    Postal Code

    Employer/School

    Occupation

    Work Phone

    Spouse Name

    Spouse Employer

    Whom may we thank for referring you to our office?

    Emergency Contact Name

    Relation

    Phone

    DENTAL HISTORY

    Reason for today’s visit

    Former Dentist Name

    Date of last dental visit

    Date of last cleaning

    Date of last dental X-ray

    Do you have or have you had any of the following? (Please check any that apply)

    Do you have any dental related issues/concerns not listed above?

    MEDICAL HEALTH HISTORY

    Are you allergic to, or have you reacted adversely to:

    Other:

    Are you taking any of the following?

    Other:

    Women:

    May be pregnant, expected due date:

    Name of the Physician:

    Phone number:

    Do you have any disease, condition, or problem not listed above?

    The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist.

    Signature of patient (or parent)

    Date: