Mer Bleue Dental Centre

The Orléans Dental Experience

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New Patient Medical History Form

How did you hear about us?*

Give some Details:

Patient Contact Information

Patient Type*

Name of Guardian

First Last

Gender*

Male

Female

Other

Name of Patient*

First Last

Date of Birth*

MM slash DD slash YYYY

Address*

Street Address

City*

Province*

Postal Code*

Country*

Email*

Home Phone Number

Preferred Contact Number*

Work Phone Number

Best way to contact you:*

Preferred Number

Home

Work

Family Physician*

Specialist Name

Emergency Contact*

Emergency Contact Phone Number*

Insurance Information

Primary Insurance Company

Insurance Policy Holder*

Self

Spouse

Parent/Guardian

None of the Above

Insurance Company Name

Name of Insurance Policy Holder

Holder Date of Birth

MM slash DD slash YYYY

Group Policy/Plan Number

ID/Certificate Number

Secondary Insurance Company Information

Insurance Policy Holder

Self

Spouse

Parent/Guardian

Other

Insurance Company Name

Name of Insurance Policy Holder

Policy Holder Date of Birth

Group Policy/Plan Number

ID/Certificate Number

Financial Information

Person responsible for account*

Self

Spouse

Parent/Guardian

Other

Name of Guardian

First Last

Preferred Method of Payment*

Interact

Visa

Cash

Mastercard

Dental History

Date 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?*

On a scale of 1 to 10, with 10 being the highest rating

Where would you rate your current dental health?*

On a scale of 1 to 10, with 10 being the highest rating

Why 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 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 in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year?*

Yes

Please Describe:

Has there been any change in your general health in the past year?*

Yes

Please Describe:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Yes

Please Describe:

Do you have any allergies?*

Yes

Please Describe:

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

Yes

Please Describe:

Do you have or have you ever had asthma?*

Yes

Do you have or have you ever had any heart or blood pressure problems?*

Yes

Please Describe:

Do 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

Please Describe:

Do you have a prosthetic or artificial joint?*

Yes

Please Describe:

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Describe:

Have you ever been hospitalized for any illnesses or operations?*

Yes

Please Describe:

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

Please Describe:

Do you smoke or use other nicotine products?*

Yes

Are you breastfeeding or pregnant?*

Yes

Please Describe:

Do you have a disability or are a person with visual impairment*

Yes

Please Describe:

General Release

I 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 above

Date

MM slash DD slash YYYY

Mer Bleue Dental Centre

New Patient Medical History Form

Patient Contact Information

Insurance Information

Primary Insurance Company

Secondary Insurance Company Information

Financial Information

Dental History

Medical History

General Release

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