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New Patient Form

HomeNew Patient Form

Dentistry On Fanshawe

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 Datemm/dd/yy

Home Phone

Cell Phone

E-Mail

Address

0 /

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 visitmm/dd/yy

Date of last cleaningmm/dd/yy

Date of last dental X-raymm/dd/yy

Do you have or have you had any of the following? (Please check any that apply)

Issue with previous treatmentBad breathBleeding gumsBlisters on lips or mouthChew on one side of mouthSmokingClicking or popping jawDentureFood collection b/t teethGrinding teethGums swollen or tenderJaw pain or tirednessLoose teeth or broken fillingsMouth BreathingSensitivity to cold/hot/ sweetsOrthodontic treatmentPain around earPeriodontal treatment

Do you have any dental related issues/concerns not listed above?

MEDICAL HEALTH HISTORY

Cancer or tumorHeart DiseaseHigh or low blood pressurePacemakerTuberculosis or other lung problemsKidney diseaseHepatitis or other liver diseaseAlcoholismBlood transfusionDiabetesNeurologic conditionEpilepsy, seizures, or fainting spellsEmotional conditionArthritisHerpes or cold soresAIDS or HIV positiveMigraine headaches or frequent headachesAnemia or blood disordersAbnormal bleeding after extractions, surgery, or traumaHay fever or sinus troubleAllergies or hivesAsthma

Are you allergic to, or have you reacted adversely to:

Latex materialsPenicillin or other antibioticsLocal anesthetics (“Novocain”)Codeine or other narcoticsBarbiturates, sedatives or sleeping pillsAspirin

Other:

Are you taking any of the following?

AspirinAnticoagulants (Blood thinners)Antibiotics or sulfa drugsHigh blood pressure medicineAntidepressants or tranquilizersInsulinNitroglycerinCortisone or other steroidsOsteoporosis (bone density) medicine

Other:

Women:

May be pregnant, expected due date:mm/dd/yy

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:mm/dd/yy

reCaptcha v3

Contact Us

94 Fanshawe Park Rd E Unit-3
London, ON N5X 4C5
(519) 672-9779
reception@dentistryfanshawe.ca

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