NEW PATIENT FORM

admin@thrivedental.ca (604)620-4660

Please write your full name:*

Date of birth*

Gender:*

Marital Status:*

How did you find us?*

GoogleFriends/FamilyOther

Phone number: *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Insurance Carrier:

Group Number:

ID Number:

Policy Holder's Last Name:

Policy Holder's First Name:

Policy Holder's Birthdate

Policy Holder's Relationship to Patient:

Insurance Carrier:

Group Number:

ID Number:

Policy Holder's Last Name:

Policy Holder's First Name:

Policy Holder's Birthdate:

Policy Holder's Relationship to Patient:

Do you have any of the following conditions?*

Are you under the care of a physician?*

YesNo

If yes, include name, address, phone number and reason.

Have there been any changes in your health in the past year?*

YesNo

If yes, please explain.

Date of last physical exam?*

Have you been hospitalized in the past 5 years?*

YesNo

If yes, list reason and date.

Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken. Please say "No medication" if not. *

Do you use tobacco/alcohol/street drugs?*

YesNo

If yes, what kind, how often.

Are you?

Taking birth control or hormone replacementNursingPregnant or trying to get pregnant

Are you allergic to or had a reaction to the following?*

If yes to any please specify type and reaction.

Please indicate if you have or have had any of the following diseases or problems:*

If yes to any, list dates, kinds, controlled or uncontrolled

Has a physician or dentist recommended that you take antibiotics prior to dental treatment?*

YesNo

If yes, please list the medication(s) and the reason you are taking them.

Are you currently experiencing pain in your mouth?*

YesNo

If yes, where at, what type and for how long? Please explain.

If you are experiencing pain, how do you rate it on a scale 1 to 10?

If you are experiencing any infection, swelling, bleeding or trauma in your face/mouth, please explain the situation.*

Take photo of the affected area (face/teeth) if possible.

Additional photo.

Please indicate:*

Do your gums bleed when you brush or floss?Do your teeth experience sensitivity to cold or hot temperatures?Are any of your teeth currently causing you pain?Do you grind your teeth (either consciously or during sleep)?Are any of your teeth loose, or are you concerned about any teeth loosening?Do you currently have any dental implants, dentures, or partials?Conditions listed are not applicable

If the previous questions are marked, please explain:

Authorization

I hereby certify that I have read and understand the previous information and that is accurate and true to the best of my knowledge. I acknowledge that providing incorrect/ and or inaccurate information has the potential of being harzadous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropiate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examinations for myself and my dependent(s) to any third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payments of all services rendered on my behalf or on behalf of my dependents (if any).

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Signature of patient, parent, or guardian:*

Relationship to patient *

Date*

Date

Primary Insurance

Secondary Insurance

Medical & Dental History