Are you a new patient of our clinic??New Patient Form Step 1 of 6 - Personal Information16%Name* First Name Last Name Email* Home Phone*Cell Phone*Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Gender*FemaleMaleOtherEmergency Contact*Emergency Contact Number*How did you hear about us?* Employer*Occupation*Do you have Dental Insurance?*YesNoName of Dental Insurance Subscriber* First Name Last Name Date of Birth of Subscriber* Name of Insurance Provider*Group/Plan Number*Certificate/ID Number*Do you have a Second Insurance Provider?*YesNoName of Dental Insurance Subscriber* First Name Last Name Date of Birth of Subscriber* Name of 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 you have any Pain or Discomfort?*YesNoDo your Gums feel tender/swollen?*YesNoDo your Gums bleed?*YesNoDo you have bad breath or a bad taste in your mouth?*YesNoHave you had excessive bleeding during past dental visits?*YesNoDo you grind/clench your tooth or notice any popping/clicking noises?*YesNoDo you wear a night guard?*YesNoDo you suffer from frequent migraines?*YesNoIs snoring a problem for you?*YesNoAre you happy with the way your smile looks?*YesNo Do you have any serious Medical Conditions we should know about?*Known Medical Conditions*No Known Medical IssuesAlcohol/ Drug AbuseAnginaArthritisAsthmaBlood DisorderCancerChemotherapyCongenital Heart DefectDiabetesDizziness/FaintingEmphysemaEpilepsy/SeizuresFrequent HeadachesGag ReflexHay FeverHead InjuriesHearing DisabledHeart AttackHeart MurmurHemophiliaHepatitis A/B/CHigh Blood PressureHIV/AIDSJoint Replacement (hip, knee, etc)Kidney DiseaseLiver DiseaseLow Blood PressureLung Disease/ TuberculosisMental DisorderMitral Valve ProlapseMultiple SclerosisPacemakerRadiation TherapyRespiratory ProblemsSinus ProblemSTDStomach/Intestinal ProblemsStrokeThyroid DisorderUlcerOtherPlease select each Medical Condition that is applicable for you!If Other selected, please specify:*Do you have any allergies to medication or substances?*YesNoWhat Allergies do you have?*Are you taking any prescription medication or herbal remedies?*YesNoPlease list off your medications*Do you need to be medicated with antibiotics prior to dental treatment*YesNoDo you smoke or use chewing tobacco?*YesNoHave you ever been treated for any other illness not listed above?*YesNoAre you pregnant or nursing?*YesNoHow far along is your pregnancy?*YesNoAre you nursing?*YesNo Have you recently been under the care of a physician?*YesNoName of Physician*Physician's Number*When was your last visit with the physician?*Current Health Condition*ExcellentGoodFairPoor Have anymore 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. CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.