Step 1 of 5 - Personal Information

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Name*

First Name Last Name

Preferred First Name

Email*

Home Phone

Cell Phone*

Date of Birth*

Address*

Street Address City Province Postal Code

Gender*

Male

Female

Other

Emergency Contact*

Emergency Contact Number

How did you hear about us?*

Google Ads

Google Maps/Google Search

I Live Nearby

Referred By Friend

Social (Facebook, Instagram & Youtube)

Billboard Signs

Other

Employer

Occupation

Do you have Dental Insurance?

Yes

Name of Dental Insurance Subscriber

First Name Last Name

Date of Birth of Subscriber

MM slash DD slash YYYY

Insurance Provider

Group/Plan Number

Certificate/ID Number

Do you have a second Insurance Provider?

Yes

Name of Dental Insurance Subscriber

First Name Last Name

Date of Birth of Subscriber

MM slash DD slash YYYY

Insurance Provider

Group/Plan Number

Certificate/ID Number

What's your main concern right now?*

When was your last dental visit?*

Previous Dental Office*

Do your Gums feel tender/swollen?*

Yes

Do your Gums bleed?*

Yes

Do you have bad breath or a bad taste in your mouth?*

Yes

Have you had excessive bleeding during past dental visits?*

Yes

Do you grind/clench your tooth or notice any popping/clicking noises?*

Yes

Do you wear a night guard?*

Yes

Do you suffer from frequent migraines?*

Yes

Is snoring a problem for you?*

Yes

Have you considered Botox treatment?*

Yes

Are you happy with the way your smile looks?*

Yes

Do you have any serious Medical Conditions we should know about?*

Yes

Please explain.

Known Medical Conditions*

No Known Medical Issues

Alcohol/ Drug Abuse

Angina

Arthritis

Asthma

Blood Disorder

Cancer

Chemotherapy

Congenital Heart Defect

Diabetes

Dizziness/Fainting

Emphysema

Epilepsy/Seizures

Frequent Headaches

Gag Reflex

Hay Fever

Head Injuries

Hearing Disabled

Heart Attack

Heart Murmur

Hemophilia

Please select each Medical Condition that is applicable for you!

Known Medical Conditions cont'd*

No Known Medical Condition

Hepatitis A/B/C

High Blood Pressure

HIV/AIDS

Joint Replacement (hip, knee, etc)

Kidney Disease

Liver Disease

Low Blood Pressure

Lung Disease/ Tuberculosis

Mental Disorder

Mitral Valve Prolapse

Multiple Sclerosis

Pacemaker

Radiation Therapy

Respiratory Problems

Sinus Problem

STD

Stomach/Intestinal Problems

Stroke

Thyroid Disorder

Ulcer

Other

If Other selected, please specify:*

Do you have any allergies to medication or substances?*

Yes

What Allergies do you have?

Are you taking any prescription medication or herbal remedies?*

Yes

Please list off your medications*

Do you need to be medicated with antibiotics prior to dental treatment?*

Yes

Do you smoke or use chewing tobacco?*

Yes

Have you ever been treated for any other illness not listed above?*

Yes

If Yes selected, please specify:*

Are you pregnant and/or nursing?*

Pregnant

Nursing

How far along is your pregnancy?*

Have you recently been under the care of a physician?*

Yes

Name of Physician*

Physician's Phone Number

When was your last visit with the physician?*

Current Health Condition*

Excellent

Good

Fair

Poor

Today's Date*

DD slash MM slash YYYY

Is there any other information you want to tell us?

Consent*

I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize Parkway Smiles Dental to preform any necessary dental services that I may need.

I am aware of Parkway Smiles Dental's cancellation policy which states that short notice cancellations within 48 business hours or failure to come for appointments may result in a $150 fee.*

Signature*

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