New Patient Form

If you’re a new patient to RiverEdge Dental, please complete and submit your COVID-19 Screening Form first before completing your new patient form for your first appointment.

Who may we thank for referring you ?

Select a Location*

Are you a new or current patient?*

New Patient

Current Patient

Other

Patient Contact Information

Patient Type*

Adult

Child

Adult Under Guardianship

Name of Guardian*

Gender*

Male

Female

Other

Other:

Name of Patient*

Date of Birth*

Address*

City*

Province*

Postal Code*

Country*

Email*

Home Phone Number*

Cell Phone Number*

Work Phone Number*

Best way to contact you:*

Cell

Home

Work

Family Physician*

Specialist Name*

Emergency Contact

Emergency Contact Phone Number

Insurance Information

Primary Insurance Company

Insurance Policy Holder*

Self

Spouse

Parent/Guardian

Insurance Company Name*

Name of Insurance Policy Holder*

Holder Date of Birth*

Group Policy/Plan Number*

ID/Certificate Number*

Secondary Insurance Company Information

Insurance Policy Holder*

Self

Spouse

Parent/Guardian

Other

Insurance Company Name*

Name of Insurance Policy Holder*

Policy Holder Date of Birth*

Group Policy/Plan Number*

ID/Certificate Number*

Financial Information

Person responsible for account*

Self

Spouse

Parent/Guardian

Other

Name of Guardian*

Preferred Method of Payment*

Interact

Visa

Cash

Mastercard

Dental History

Date of your last dental exam*

Date of your last dental cleaning*

Date of your last dental xrays*

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

Sensitivity (hot, cold and/or sweet)

Tooth pain or discomfort while chewing

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 the above

Do you have, or have you had any of the following?*

If you could change your smile, you would…*

How important is your dental health to you?*

On a scale of 1 to 10, with 10 being the highest rating

Where would you rate your current dental health?*

On a scale of 1 to 10, with 10 being the highest rating

Why are you leaving your previous Dentist?*

What, if anything, in the past has kept you from having dental treatment?*

What is the most important thing about your future smile and dental health?*

What is most important thing to you about your upcoming visit?*

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist 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

Please Describe:

Has there been any change in your general health in the past year?*

Yes

Please Describe:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Yes

Please Describe:

Do you have any allergies?*

Yes

Please Describe:

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes

Please Describe:

Do you have or have you ever had asthma?*

Yes

Do you have or have you ever had any heart or blood pressure problems?*

Yes

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

Please Describe:

Do you have a prosthetic or artificial joint?*

Yes

Please Describe:

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Describe:

Have you ever been hospitalized for any illnesses or operations?*

Yes

Please Describe:

Do you have or have you ever had any of the following? Please check all that apply.*

Are there any conditions or diseases not listed above that you have or have had?*

Yes

Please Describe:

Do you smoke or use other nicotine products?*

Yes

Are you breastfeeding or pregnant?*

Yes

Do you have a disability or are a person with visual impairment*

Yes

Please Describe:

General Release

I agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.*

I agree

I do not agree

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 dentist 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 dentist shall be governed and construed in accordance with the laws of the province of Ontario.

Signature*

Use your mouse or finger to draw your signature above

Date