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Home
+
About Us
+
Our Team
+
Our Services
+
Extractions
+
Full Mouth Restoration
+
Implant Restoration
+
Migraine
+
Non-Surgical Gum Therapy
+
Orthodontics and Orthopedics
+
Porcelain Inlays and Onlays
+
Athletic Mouth Wear
+
Root Canal Therapy
+
Sedation
+
Dental Bridges
+
Crowns
+
Dental Bonding
+
TMJ (TMD) Therapy
+
Videos
+
TMJ Headaches
+
Blog
+
Office Updates
+
Location
+
Milton
+
Brampton
+
Contact Us
+
New Patient Form
Home
New Patient Form
SapphireDentalCentre
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
1
Step 1
Patient Last name
First name
Sex
Birth Date
date_range
Home Phone
Cell Phone
E-Mail
email
Address
City
Prov.
Postal Code
Employer/School
Occupation
Work Phone
Spouse Name
Spouse Employer
UNMARRIED
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_range
Date of last cleaning
date_range
Date of last dental X-ray
date_range
Do you have or have you had any of the following? (Please check any that apply)
ISSUE WITH PREVIOUS TREATMENT
BAD BREATH
BLEEDING GUMS
BLISTERS ON LIPS OR MOUTH
CHEW ON ONE SIDE OF MOUTH
SMOKING
CLICKING OR POPPING JAW
DENTURE
FOOD COLLECTION B/T TEETH
GRINDING TEETH
GUMS SWOLLEN OR TENDER
JAW PAIN OR TIREDNESS
LOOSE TEETH OR BROKEN FILLINGS
MOUTH BREATHING
SENSITIVITY TO COLD/HOT/ SWEETS
ORTHODONTIC TREATMENT
PAIN AROUND EAR
PERIODONTAL TREATMENT
Do you have any dental related issues/concerns not listed above?
MEDICAL HEALTH HISTORY
CANCER OR TUMOR
HEART DISEASE
HIGH OR LOW BLOOD PRESSURE
PACEMAKER
TUBERCULOSIS OR OTHER LUNG PROBLEMS
KIDNEY DISEASE
HEPATITIS OR OTHER LIVER DISEASE
ALCOHOLISM
BLOOD TRANSFUSION
DIABETES
NEUROLOGIC CONDITION
EPILEPSY, SEIZURES, OR FAINTING SPELLS
EMOTIONAL CONDITION
ARTHRITIS
HERPES OR COLD SORES
AIDS OR HIV POSITIVE
MIGRAINE HEADACHES OR FREQUENT HEADACHES
ANEMIA OR BLOOD DISORDERS
ABNORMAL BLEEDING AFTER EXTRACTIONS, SURGERY, OR TRAUMA
HAY FEVER OR SINUS TROUBLE
ALLERGIES OR HIVES
ASTHMA
Are you allergic to, or have you reacted adversely to:
LATEX MATERIALS
PENICILLIN OR OTHER ANTIBIOTICS
LOCAL ANESTHETICS (“NOVOCAIN”)
CODEINE OR OTHER NARCOTICS
BARBITURATES, SEDATIVES OR SLEEPING PILLS
ASPIRIN
Other
Are you taking any of the following?
ASPIRIN
ANTICOAGULANTS (BLOOD THINNERS)
ANTIBIOTICS OR SULFA DRUGS
HIGH BLOOD PRESSURE MEDICINE
ANTIDEPRESSANTS OR TRANQUILIZERS
INSULIN
NITROGLYCERIN
CORTISONE OR OTHER STEROIDS
OSTEOPOROSIS (BONE DENSITY) MEDICINE
Other
Women:
May be pregnant, expected due date:
date_range
TAKING HORMONES OR CONTRACEPTIVES
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.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE OF ANY BALANCES WHICH ARE NOT PAID FROM MY INSURANCE.
Signature of patient (or parent)
Date
date_range
reCaptcha v3
Submit
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Address
433 Steeles Ave E Unit 102 Milton, ON L9T 8Z4
Call us today!
(905) 878-8760 Ext 1
Appointment Booking
info@sapphiredentalcentre.com
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