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General Dentistry
Dental Exams Leslieville
Dental Cleaning Leslieville
Dental Extraction Leslieville
Wisdom Teeth Removal Leslieville
Pediatric Dentist Leslieville
Family Dentist Leslieville
Scaling and Root Planing Leslieville
Cosmetic Dentistry
Dental Veneers Leslieville
Orthodontics Leslieville
Invisalign Leslieville
Teeth Whitening Leslieville
Restorative Dentistry
Dental Fillings Leslieville
Dentures Leslieville
Dental Implants Leslieville
Dental Crowns Leslieville
Dental Bridges Leslieville
Periodontics Leslieville
Endodontics Leslieville
Root Canal Therapy Leslieville
TMJ Disorders Leslieville
Emergency Dental Treatments Leslieville
Forms
Patient Registration Form – Child
Patient Registration Form – Adult
Insurance
CDCP
Blogs
Home
About
Contact
Services
General Dentistry
Dental Exams Leslieville
Dental Cleaning Leslieville
Dental Extraction Leslieville
Wisdom Teeth Removal Leslieville
Pediatric Dentist Leslieville
Family Dentist Leslieville
Scaling and Root Planing Leslieville
Cosmetic Dentistry
Dental Veneers Leslieville
Orthodontics Leslieville
Invisalign Leslieville
Teeth Whitening Leslieville
Restorative Dentistry
Dental Fillings Leslieville
Dentures Leslieville
Dental Implants Leslieville
Dental Crowns Leslieville
Dental Bridges Leslieville
Periodontics Leslieville
Endodontics Leslieville
Root Canal Therapy Leslieville
TMJ Disorders Leslieville
Emergency Dental Treatments Leslieville
Forms
Patient Registration Form – Child
Patient Registration Form – Adult
Insurance
CDCP
Blogs
New Adult Patient Registration Form
PATIENT INFORMATION
Last Name
First Name
Date of Birth (YYYY-MM-DD)
Address
City
Postal Code
Home Phone
Cell Phone
Email
Where did you hear about us?
Family/Friend
Online Search
Social Media
Newspapers/Magazines
Other
In case of emergency please contact:
Emergency Contact Number
WORK INFORMATION
Employer
Occupation
INSURANCE INFORMATION
Primary Insured
Date of Birth (YYYY-MM-DD)
Employer
Insurance Company
Group / Policy Number
ID / Certificate Number
If covered under spouse’s plan as secondary coverage:
Secondary Insured
Date of Birth (YYYY-MM-DD)
Employer
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
Date of Last Visit
In past years have you been to a dentist on a regular basis? If so how often?
Are you presently in any dental pain?
Is any part of your mouth sensitive to temperature, pressure or sweets?
Do you have an unpleasant taste or odor in your mouth?
Have you ever gotten food stuck between your teeth?
Do you awaken with pain in your teeth or jaws?
Do you have frequent headaches or facial pain?
Are you aware of jaw clicking or popping while eating or yawning?
Do you ever get cold sores or fever blisters?
What is your major dental concern at this time?
PLEASE READ THE FOLLOWING CAREFULLY
Office Policy
We will gladly complete Dental Insurance Claim Forms with the following understanding;
a)
The patient is financially responsible for the entire cost of the treatment.
b)
Payment is to be made to “Dental Land Professional Corporation” by the patient or by direct billing to the insurance company.
iTrans
Benefits payable from claims submitted electronically will be assigned to Dental Land and payment will be received by the Dentist directly.
CANCELLATION/ NO SHOW POLICY
At least 24 hours notice is required if you must cancel/reschedule your appointment for any reason.
Missed Appointments will incur a firm charge of $50.00
All outstanding fees must be paid in full before further appointments will be booked.
Should you miss an appointment, it is your responsibility to call and rebook.
Frequent or numerous cancellations and/or no shows will result in permanent discharge from the practice.
Statement of Understanding
I hereby acknowledge and confirm that I have read the policy stated above. I agree to conduct my activities in accordance with Dental Land Professional Corporation's policy and understand that breaching it in anyway may result in disciplinary action.
Name of Patient
Date Signed
Message
By checking this checkbox, I hereby understand and agree to the conditions mentioned above.
Send
