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NEW PATIENT FORM
Dear New Patient,
We want to take this time to welcome you to Mclean Teeth Dental Hygiene Care! Thank you for choosing us to be part of your dental hygiene care journey :)
Your time is valuable to us, so to make your first visit quick and easy, kindly complete this form at your own convenience before your appointment.
If you would like to complete this form at our office, you are more than welcome to! Please ask for assistance with any questions or concerns you may have by sending us an
email
or giving us a
call
anytime!
Thanks, and we're looking forward to meeting you soon!
Sincerly,
The Mclean Teeth Team
REFERRAL INFORMATION
How Did You Hear About Mclean Teeth?
*
Social Media
Lives in Area
Works in Area
Friend or Family
Patient Referral
Employee Referral
Event
Search Engine
Other
Check all that applies to you
If other, please specify
*
Hi there, new patient!
I am Alicia Thompson, the co-founder and CEO of Mclean Teeth.
I will be your office manager and dental assistant. I aim to help you on your first day at Mclean Teeth and familiarize you with the home-based studio! I am very familiar with the dental environment and can help answer any questions or concerns you may have about who we are and what we do here at Mclean Teeth. It is in my best interest to ensure that all patients have a positive experience at Mclean Teeth. On behalf of me and The Mclean Teeth Team, we are so excited that you are here! Thank you for choosing us to be a part of your dental hygiene care journey.
Looking forward to meeting you soon!
Sincerly,
Alicia Thompson :)
PATIENT CONTACT INFORMATION
*
Indicates required field
Title
*
Mr.
Mrs.
Ms.
Mst.
Miss.
Dr.
Please choose one
Name
*
First
Last
Date of Birth
*
Year/ Month/ Day
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
Cell Phone Number
*
Work Phone Number
*
Email
*
Preferred Method of Contact
*
Email Address
Home Phone Number
Cell Phone Number
Work Phone Number
Check all that applies to you
Occupation
*
Name of guardian/parents (if under 18 or under guardianship)
*
In case of emergency who should we contact?
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone Number
*
Name of Family Doctor
*
Family Physician
*
Province and City Name
*
Family Doctor Phone Number
*
Specialist Name
*
Specialist Phone Number
*
Pharmacy Name/ or Number
*
INSURANCE REGISTRATION
Do you have dental insurance?
*
Yes
No
Please choose one. You may skip this part of the form if you DO NOT have dental insurance.
If you have answered "yes", please complete the following information. If you do not have dental insurance, please skip this part of the form.
PRIMARY INSURANCE
Insurance Policy Holder
*
Self
Spouse
Parent/Guardian
Other
Please choose one
Insurance Company Name
*
Subscriber's Employer
*
Name of Insurance Policy Holder
*
Policy Holder Date of Birth
*
Day/Month/Year
Group Policy/Plan Number
*
ID/Certificate Number
*
SECONDARY INSURANCE
Insurance Policy Holder
*
Self
Spouse
Parent/Guardian
Other
Please choose one
Insurance Company Name
*
Subscriber's Employer
*
Name of Insurance Policy Holder
*
Group Policy/Plan Number
*
ID/Certificate Number
*
Policy Holder Date of Birth
*
MEDICAL HISTORY
The following information is required to enable us to provide you with the best possible dental hygiene care. All information is strictly private and is protected by dental hygienist-patient confidentiality. The dental hygienist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year
*
Yes
No
Maybe/ Not sure
Please choose one
When was your last medical checkup?
*
Day/Month/Year (Please Provide a Rough Estimate if Uncertain)
Has there been any change in your general health in the past year?
*
Yes
No
Maybe/ Not sure
Please choose one
Do you have any allergies
*
Yes
No
Maybe/ Not sure
Please choose one
If so, what are they?
*
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
*
Yes
No
Maybe/ Not sure
Please choose one
Have you ever had a peculiar or adverse reaction to any medicines or injections
*
Yes
No
Maybe/ Not sure
Please choose one
If so, what are they?
*
Do you have or have you ever had any heart or blood pressure problems?
*
Yes
No
Maybe/ Not sure
Please choose one
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
*
Yes
No
Please choose one
Do you have a prosthetic or artificial joint? (i.e. knee or hip?)
*
Yes
No
Please choose one
Do you have or have you ever had any of the following?
*
chest pain, angina
rheumatic fever
pacemaker
steroid therapy
heart attack
mitral valve prolapse
lung disease
diabetes
kidney disease
stroke, TIA
tuberculosis
stomach ulcers
thyroid disease
shortness of breath
heart murmur
cancer
arthritis
drug/alcohol/cannabis use or dependency
osteoporosis medications (e.g. Fosamax, Actonel)
None of these apply to me
Please check all that applies to you.
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
*
Yes
No
Maybe/ Not sure
Please choose one
Are there any conditions or diseases not listed above that you have or have had
*
Yes
No
Please choose one
If so, please specify what they are
*
Do you smoke or use other nicotine products?
*
Yes
No
Please choose one
Are there any diseases that run in the family? (e.g. diabetes, cancer, heart disease)
*
Yes
No
Maybe/ Not sure
Please choose one
For Women Only:
Are you pregnant?
*
Yes
No
Please choose one
If so, what is your expected delivery date?
*
Are you breast feeding?
*
Yes
No
Please choose one
Do you take birth control pills
*
Yes
No
Please choose one
DENTAL HISTORY
Date of Your Last Dental Visit?
*
Please Provide a Rough Estimate if Uncertain
Date of Your Last Dental Cleaning?
*
Please Provide a Rough Estimate if Uncertain
Who was Your Previous Dentist?
*
Date of Your Last Dental X-rays
*
Please Provide a Rough Estimate if Uncertain
How Would You Describe Your Teeth?
*
Good
Fair
Poor
Please Check Any of the Following Problems that May: Apply to You
*
Sensitivity (hot, cold, and/or sweet)
Tooth Pain
Headaches, earaches, or neck pain
Jaw joint pain (clicking/cracking)
Grinding or clenching teeth
Bleeding swollen or irritated gums
Loose, chipped, or shifting teeth
Bad breath or bad taste in your mouth
None of these apply to me
Check all that applies to you
Are you dissatisfied with the appearance of your teeth
*
Yes
No
Maybe/ not sure
Any teeth extracted due to accident, decay, or gum disease?
*
Yes
No
Maybe/ Not sure
If yes, please explain
*
Have you ever had any complications after extractions?
*
Yes
No
Maybe/ Not sure
Are you anxious during dental visits?
*
Yes
No
Maybe/ Not sure
Do you think you might like to have your dental treatment done with sedation?
*
Yes
No
Maybe/ Not sure
Do you use any of the following as part of your oral hygiene regiment?
*
electric toothbrush
waterpic
floss
fluoride rinse/tablet
softpics
fluoridated toothpaste
proxybrush
natural toothpaste
stimudent
flosswand
prevident toothpaste
toothpic
rubbertip
Other(s)
*
GENERAL RELEASE
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dental hygienist shall be governed and construed in accordance with the laws of the province of Ontario.
Click here to read the consent form!
Do you agree to the patient certification and consent?
*
I agree
I do not agree
Please choose one
Signature (Place your full name below)
*
Submit
ALL DONE!
Home
About
Services
Teeth Cleaning
Teeth Whitening
Additional Services
Dental Hygiene for Kids
FAQ
News
Contact
Forms
Dental Boutique
Mclean Teeth Products
Whitening Products