Dr. William Rodriguez Dentistry Professional Corporation

#125 - 350 Burnhamthorpe Road West, Mississauga, ON L5B 3J1

905-277-3088

PATIENT INTAKE FORM

The information in this form is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete it as accurately as possible. Thank you.

PATIENT CONTACT INFORMATION

Patient's Full Name:
Preferred Name:
Patient's Date of Birth:
Gender:

Address:
City:
Province:
Postal Code:
Home Number:
Work Number:
Cell Number:
Email Address:
Employer/School:
Position/Occupation:
Best way to contact you?
 
Person to contact in case of an emergency (relationship):
Phone Number
Family Doctor:
Phone Number:
Pharmacy Name:
Phone Number:







INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY INFORMATION

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Other Details:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number

SECONDARY INSURANCE COMPANY INFORMATION

Name of Insurance Policy Holder:
Date of Birth:
Insurance Policy Holder:
Other Details:
Policy Holder Phone Number (if different from above):
Employer:
Insurance Company Name:
Group Policy/Plan Number:
I.D./Certificate Number

METHOD OF PAYMENT

REFERRAL INFORMATION

How did you hear about us? (Check all that apply)
 
 

Medical History

Have you had a medical check-up in the last year?

If yes, when?
Have you ever been hospitalized or had major surgeries?

If yes, please explain:
Are you currently under a physician's care?

If yes, what for?
Have you ever had an unusual reaction to any medications or injections?

If yes, please describe:
Are you taking any medications, non-prescription drugs, recreational drugs, or herbal supplements?

If yes, please specify:
Do you drink, smoke, vape or chew tobacco products?

If yes, explain:
Do you require pre-medication for dental treatment?

Details:
Have you ever had any organ implant or medical implants? (i.e. valves, stents, joints, pacemakers)

If yes, please specify:
Do you experience shortness of breath or chest pains when taking a walk or climbing stairs?

If yes, please specify:
Have you had any injury, surgery or x-ray therapy to your face or jaws?

If yes, please specify:
For Women Only:
Are you pregnant or suspect you might be?

If so, what month are you in?
Are you taking birth control pills?

Are you nursing?

Do you have or have ever had any of the following:
Yes No Yes No
AIDS High blood pressure
Allergies, seasonal HIV positive
Anemia HPV
Arthritis Jaundice
Artificial heart valve Jaw joint pain
Artificial joints Kidney disease
Asthma Liver disease
Blood disease Low blood pressure
Bruise easily Mental illness
Cancer Mitral valve prolapse
Chemotherapy Nervousness / Depression
Diabetes Pacemaker
Dizziness Phen fen (1 month +)
Drug addiction Pregnant currently
Emphysema Respiratory problems
Excessive bleeding Rheumatic fever
Fainting Rheumatism
Glaucoma Scarlet fever
Heart conditions Seizures
Heart lesions, congenital Sleep apnea
Heart murmur Stomach problems
Heart surgery Stroke
Hepatitis A Thyroid disease
Hepatitis B Tuberculosis
Hepatitis C Ulcers
Venereal diseases
Do you or have you ever had any other illness not listed above?

If yes, please explain:

Do you have any of the following allergies?

Yes No Yes No
Aspirin Nitrous oxide
Codeine Penicillin
Erythromycin Percocet
Latex Sulpha
Local anaesthetic Valium
Other

Dental History

What is your main priority in seeking dental treatment?
How frequently did you see your previous dentist?

Date of Last Dental Visit:
Date of Last Hygiene Visit:
Date of Last Dental X-ray:
Your Last Oral Cancer Screening:
How often do you brush your teeth?
How often do you floss?
Do your gums bleed easily?

Please check any of the following problems that may apply to you:

Yes No Yes No
Sensitivity (hot, cold and/or sweet) Bleeding gums or fillings
Loose, tipped or shifting teeth Bad breath or bad taste in your mouth
Tooth pain or discomfort while chewing Broken teeth or fillings
Headaches, earaches or neck pain Jaw joint pain (clicking/cracking)
Sore spots / growths
Have you had any negative experiences with your previous dentist?

Have you ever had difficulty getting numb/frozen?



Do you have or have had any of the following?

Yes No Yes No
Orthodontics Oral Surgery
Gum treatment Root Canal
Implants Dentures
Night Guard Braces

If you could change your smile, you would...

Yes No Yes No
Whiter teeth Straighter teeth
Close spaces Replace black metal fillings with natural, tooth coloured fillings
Repair chipped teeth Replace missing teeth
Replace old crowns that don't match Smile makeover
Other dental concerns:

PRIVACY & RELEASE INFORMATION

Release of Information: I authorize Dr. William Rodriguez Dentistry Professional Corporation to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history from my physician, another dental office and/or insurance company.

Office Policy: My appointment time is reserved for me. If I am unable to keep the appointment, I am required to give two (2) days notice. Otherwise, a charge of $75.00 will be added to my account.

Patient Release: I understand that providing incorrect information can be dangerous to my (or my dependent's) health. It is my responsibility to inform the dental office of any changes in my medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

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