Patient Information Form | Meadowbrook Dental Centre

Last Name

First Name(s)

Date of Birth

Sex

Home Phone

Cell Phone

Work Phone

Address

City

Postal Code

Email Address

Emergency Contact

Emergency Phone

Relationship

Do you have Dental Insurance?

Insurance Company

Policy/Contract Number

Certificate/Member ID Number

Cardholders Name

Date of Birth

If you were referred to our office, whom may we thank?

Last Dental Exam

Have you ever been referred for sedation?

Are you nervous/anxious during dental treatment?

Please check if you have any of the following concerns:

Health Card Number

Physician

Height

Weight

Are you presently being treated by a pysician?

Last Medical Exam

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

If yes: name, dose, and frequency

Pharmacy Name and Location

Do you smoke or chew tobacco?

Do you drink alcohol?

If female, are you pregnant?

Do you snore or have been told that you stop breathing while you sleep?

Have you ever been hospitalized?

If so, why?

Do you have a prosthetic heart valve?

Do you have a pacemaker?

Any previous surgery?

If so, what?

Have you ever had radiation treatment to your head or neck?

Is there any condition that we should be aware of that would assist us with your treatment?

Have you ever been treated for any of the following?

Do you have any allergies?

Please check any allergies

Other

Opt-In

By checking, I agree that the information I have given above is true and to the best of my knowledge.

Opt-In

I have reviewed the PRIVACY POLICIES that explain how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time.

Opt-In

I agree that Dr. Christopher Godbout and Associates can collect, use and disclose personal information as explained in the office's PRIVACY POLICIES.

Patient/Parent/Guardian Electronic Signature

Opt-In

I understand that my electronic signature is of the same legal equivalence to my physical signature.

Date

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