New Patient Intake Form

WELCOME TO MULKINS MAIN DENTAL

Adult
Child

Name

First Middle Last

Prefers to be called

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Date of Birth

Male
Female

Employer

Phone

Occupation

School

Grade

Would you be available on short notice for future appointments or appointment changes?

May we call you at work?

Email

Whom may we thank for referring you to our office?

Family Physician:

Phone

In case of emergency

Relation

Phone

Person responsible for this account:

Self
Spouse
Parent
Legal Guardian
Other

Person responsible for this account Other Option Selected

Name

First Middle Last

Prefers to be called

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Payment by

Cash
Cheque
Credit Card

Credit Card Number

Credit Card Expiry Date

Primary Insurance

Subscriber

Relation (Primary)

Self
Spouse
Other

Primary Insurance Relation Other

Insurance Co

Policy / Plan

Division/Sect

Subscriber ID or S.I.N. #

Are you familiar with your plan details?

Yes
No

Coverage

A
B
C
D

SecondaryInsurance

Subscriber

Relation (Secondary)

Self
Spouse
Other

Secondary Insurance Relation Other

Insurance Co

Policy / Plan

Division/Sect

Subscriber ID or S.I.N. #

Are you familiar with your plan details?

Yes
No

Coverage

A
B
C
D

MEDICAL HISTORY

All information is confidential
Y =Yes ? =Don’t know/Maybe N = No
The following information is required by the dentist to assist in proper diagnosis and treatment

1. Have you ever had a serious illness requiring hospitalization or extensive medical care?

Y
N
?

Please specify:

2. Have you been hospitalized in the last 5 years?

Y
N
?

3. Are you presently under the care of a physician?

Y
N
?

If yes, why?

4. Have you had medical examination in the last year?

Y
N
?

5. Do you use any prescription or non-prescription drugs regularly?

Y
N
?

Please specify:

6. Do you have any allergic conditions: i.e. Hay fever, skin rash, food allergies, metal, latex?

Y
N
?

Please specify:

7. Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea?

Y
N
?

Please specify:

8. Have you ever experienced any unusual reaction to any of the following (please circle) Local anesthesia (freezing), aspirin, penicillin, codeine, sulpha drugs, barbiturates (sleeping pills), or any other medicine?

Y
N
?

If so, please explain

9. Have you been warned against taking any drug or medication?

Y
N
?

10. Do you bruise easily or bleed abnormally?

Y
N
?

11. Have you ever had an organ transplant or medical implants?

Y
N
?

12. Have you ever fainted?

Y
N
?

13. Do your ankles swell during the day?

Y
N
?

14. Do you experience shortness of breath or chest pain when taking a walk or climbing stairs?

Y
N
?

15. Do you have frequent headaches / earaches / ear or throat infections or hearing difficulty?

Y
N
?

16. Do you have AIDS or had contact with the AIDS virus or have you ever tested positive for HIV?

Y
N
?

17. Do you have or have you ever had any of the following? (please tick)

17. Do you have or have you ever had any of the following? Other Response

18. Have you had any injury, surgery or x-ray therapy to your face or jaws?

Y
N
?

19. Do you have any other disease, condition, or problem that you think the doctor should know about?

Y
N
?

Details

20. Women Only

Are you pregnant or suspect you might be? If so, what month are you in?

Y
N
?

Details

Are you taking birth control pills?

Y
N
?

Are you pregnant or suspect you might be? If so, what month are you in?

Y
N
?

info@mulkinsmaindental.ca

(613) 672-1010

Get in touch