Patient Intake Form Please fill out the form below to provide us with your necessary information for your patient intake process. Patient Intake Form Patient Information Form Step 1 of 5 20% Welcome! Thank you for selecting us. To help us provide you with the highest standard of dental care, please fill out this form completely. All information is strictly confidential. If you need assistance, please ask us and we will be happy to help you. Office Location*SurreyLangleyNorth VancouverPersonal InformationName* Prefix Mr.Mrs.MissMs. First Last Birthday - mm/dd/yyyy* MM slash DD slash YYYY Email Sex* Male Female Prefer not to say Address* Address City ZIP / Postal Code Home PhoneWork PhoneCell Phone*Person to contact in case of emergency* Phone*Name of family members who are patients at our office How did you hear about our office?* Friend / Relative Google Newpaper / flyer SNS (Facebook, etc) Whom may we thank for referring you? Reason for VisitWhat bothers you most? (chief complaint)* Do you have dental insurance?* Yes No Insurance InformationBC Care Card #* If student, name of school & If full time, enter student ID# Primary Insurance Company's Name* Dependent Name* Dependent Birthday (mm/dd/yyyy)* MM slash DD slash YYYY Policy holder's name* Insurance plan(Contract) number* Insurance ID(Certificate) number* Policy holder's Birthday (mm/dd/yyyy)* MM slash DD slash YYYY Relationship to policy holder* Do you have secondary dental insurance?* Yes No Secondary InsuranceSecondary Insurance Company's Name* Dependent Name* Dependent Birthday (mm/dd/yyyy)* MM slash DD slash YYYY Policy holder's name* Insurance plan(Contract) number* Insurance ID(Certificate) number* Policy holder's birthday (mm/dd/yyyy)* MM slash DD slash YYYY Relationship to policy holder* Medical InformationPhysician's Name Phone#1. Are you in good health?* Yes No If no, please provide details: 2. When was the last time you had a medical examination?* 3. Are you presently receiving treatment for any illness? If yes, please provide details:* Yes No If yes, please provide details: 4. Have you ever been hospitalized? If yes, please provide details:* Yes No If yes, please provide details: 5. Do you have any heart or circulatory problems?* Yes No Do you have a pacemaker? Yes No 6. Have you ever had rheumatic fever?* Yes No If yes, when: 7. Have you ever been advised to take antibiotic pre-medication before dental treatment?* Yes No 8. Do you have allergies?* Yes No If yes, please list: 9. Are you presently taking any kind of medication? If yes, please specify:* Yes No List*DrugReason 10. Have you reacted to any kind of medicine or dental local anesthetic?* Yes No If yes, please provide: 11. Female patients - Are you pregnant or think you may be pregnant?* Yes No Breastfeeding? Yes No 12. Please indicate below(v) if you presently have or have ever had any of the following:* None AIDS/HIV Alcohol or chemical dependency Arthritis or Rheumatism Artificial joints or valves Asthma Blood transfusion Cancer/radiotherapy/chemotherapy Diabetes Eating disorders Epilepsy/seizures Fainting/dizzy spells Heart surgery / Prosthetic valves / stent High/low blood pressure Hyper/hypoglycemia Osteoporosis / Osteomalacia Kidney disease Liver disease (Hepatitis/Jaundice) Lung disease/chest pains Mental or nervous disorder Stomach ulcers Stroke Tuberculosis Venereal/communicable disease 13. Do you smoke?* Yes No If yes, how much per day?* 15. Is there any additional information related to your health that has not been addressed above? Dental HistoryWhen did you see a dentist last? And, where(clinic name, location)?* How frequently do you go to a dental clinic? 6 month 1 year When did you get teeth cleaned in a dental clinic last?* Have you ever been educated about oral hygiene instructions? Yes No Have you ever had any complications with local anesthetics?* Yes No If yes, how? Have you had abnormal bleeding after dental procedures before?* Yes No If yes, by what procedure? Do you feel some pain around jaw joints when you open your mouth wide?* Yes No Do you easily gag during dental treatment?* Yes No Do you feel any discomfort when you lie down on a dental chair?* Yes No Do you have any difficulty in breathing during dental treatment?* Yes No Please check if you had the following treatments in the past:* None Orthodontic treatments (braces, Invisalign) Periodontal (Gum) Surgery Tooth Extraction Implant Surgery Jaw joints (TMJ) treatment (Splints) Treatment due to facial/oral trauma Daily Habit AssessmentHow often do you brush your teeth per day?Please enter a number from 0 to 10.Do you use dental floss? Yes No If any, do you use other hygiene tools? Do you grind or clench your teeth?* Yes No Do you habitually chew something like pencils, nails, lips, tongue? Yes No Oral Discomfort AssessmentDo you usually feel your mouth dry?* Yes No Do you have any sensitivity on your teeth (cold, hot, sweet, chew)?* Yes No Do you have gum bleeding?* Yes No Do you feel any discomfort on your jaw or cheeks when you get up in the morning?* Yes No Do you hear any sound from jaw joints when you open and close your mouth?* Yes No Do you have any difficulty in mouth opening or closing?* Yes No Do you have any headache, neckache, or shoulder pain?* Yes No Supplement AssessmentWe are happy to talk with you about your dietary issues or your esthetic needs. As orofacial professionals, we can help you with your healthy lives and happy smiles.Do you want a consultation about your dietary habits or nutritional guides?* Yes No Are you concerned with your bone health?* Yes No Are you taking any dietary supplements to improve or maintain bone health?* Yes No Do you want to change your smile by having dental treatments such as braces and veneers for cosmetic purposes?* Yes No Are you interested in facial esthetics such as BOTOX injection?* Yes No Office Policy Please help us to maintain the operation of our office so that we may assure you and other patients of uninterrupted treatment. Remember that once you have made an appointment, this time is reserved for you. Therefore, at least 24 hours' notice must be given if cancellation is absolutely necessary. Otherwise, it may be necessary to charge for the time lost. This office bases its fees on the current British Columbia Dental Association General Practitioner's Fee Guide. However, if a particular procedure requires a significantly longer time than usual, where exceptional effort or skill is required, or unusual complications are present, a higher fee may be charged. Service is to be paid for at each visit as they are performed unless prior arrangements have been approved. There will be a 1.5% administration fee per month on all accounts over 30 days old. Accounts over 90 days old will be sent to a collection agency. If you authorize us to do so, this office is willing to accept direct payment from your dental insurance plan for services while your plan covers and is not based on the assumption that the insurance plan will pay the full cost of your treatment. You must pay your portion for the dental service according to your insurance policy. To help our staff to concentrate more on your safety in the office while pandemic goes on and after it ends, you may be asked to pay all treatment fees on the date of the service, and the insurance company will reimburse you later. We can submit the claim to your insurance for you. Thus, there is nothing you need to do. You are responsible for providing the necessary information in order for us to directly bill your insurance plan as well as informing us of any changes in this information. If your dental plan does not cover the full cost of your treatment, you will be responsible for any difference between the amount paid by your plan and the amount charged. Your portion is then due and payable on the day of your appointment. I have read and fully understand the above office policy statements. I consent to the terms.* I agreeI have read and fully understand the above office policy statements. I consent to the terms.Patient Rights and ConsentI have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I have the opportunity to ask any questions and receive answers regarding this Medical/Dental history and I consent to my physician being contacted if necessary. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.* I agreeI have provided an accurate and complete Medical/Dental history and have not knowingly omitted any information. I have the opportunity to ask any questions and receive answers regarding this Medical/Dental history and I consent to my physician being contacted if necessary. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.I authorize this office to consult with or transfer my dental records to/from a medical doctor, specialist or other dentists if necessary or requested* I agreeI authorize this office to consult with or transfer my dental records to/from a medical doctor, specialist or other dentists if necessary or requestedI authorized the dentist and his or her qualified staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I understand that refusal to do may result in compromised treatment.* I agreeI authorized the dentist and his or her qualified staff to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I understand that refusal to do may result in compromised treatment.I authorize the dentist to perform any or all forms of treatment, medication, and therapy that may be indicated and consent to the use of local anesthetic agents.* I agreeI authorize the dentist to perform any or all forms of treatment, medication, and therapy that may be indicated and consent to the use of local anesthetic agents.As a patient, I understand that I have the right to be advised of the benefits, options, risks, and potential complications of any dental procedure, ask questions and receive complete answers regarding my oral health, and make an informed decision to accept or decline recommended treatment.* I agreeAs a patient, I understand that I have the right to be advised of the benefits, options, risks, and potential complications of any dental procedure, ask questions and receive complete answers regarding my oral health, and make an informed decision to accept or decline recommended treatment.I agree that responsibility for payment of dental services by this office for myself or my dependents is mine (whether or not paid by insurance) and payable at the time services are rendered unless other financial arrangements have been made.* I agreeI agree that responsibility for payment of dental services by this office for myself or my dependents is mine (whether or not paid by insurance) and payable at the time services are rendered unless other financial arrangements have been made.Disclosure of photos, x-rays, and models - I consent to the disclosure of photography, filming, recording, models, and x-rays of mine for the purpose of patient education, consultation, advertisement, and publication, provided that my identity is NOT revealed.* Yes No SignaturePatient or guardian* Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.