10215 Kennedy Road North Units 8 & 9 Brampton, ON Make Appointment Email Us 905-846-7776 NEW PATIENT FORM 2540077 Northlake Dentistry New Patient Form Contact Northlake Dentistry NEW PATIENT REGISTRATION FORMTitle Mr. Mrs. Miss Dr.(GIVEN NAME)(FAMILY NAME)Date of Birth:Address ( NUMBER, STREET, APT)CityPostal CodeHome PhoneCell PhoneWork PhoneWork phone Ext.EmailReferred by:Physician NameTel:EMERGENCY INFOIn case of Emergency, please contactEmergency Contact PersonEmergency Contact NumberRelationshipDENTAL INSURANCEDo you have dental Insurance? Yes NoDENTAL HISTORYReason for today's visit?When was your last dental exam?Last X-Rays?How often do you brush?How often do you floss?Are you interested in teeth whitening? Yes NoMEDICAL HISTORYAre you presently under the care of a physician? Yes NoHave you ever been hospitalized? Yes NoPlease Specify:Do you have a heart or circulatory problem? Yes NoPlease Specify:Do you have any allergies? Yes NoPlease Specify:Is Snoring or Sleep Apnea a concern? Yes NoDo you presently or have you ever had: Anemia Arthritis Asthma Blood Disorder Cancer Diabetes Epilepsy / seizures Hay Fever Herpes Hemorrhage High (Low) blood pressure Hyper (Hypo) glycemia Kidney disease Liver Disease Lung Disease Mental/Nervous Disorder Migraine/Headaches Prosthetic ( Joints) Rheumatism Rheumatic/Scarlet Fever Stomach (intestinal) Ulcer Stroke Thyroid problem Tuberclosis Venereal Disease HIV + BloodAre you taking any medication? Yes NoPlease Specify:Have you ever fainted? Yes NoDo you use tobacco products? Yes NoPlease Specify:Have you ever had any illness not listed above Yes NoPlease Specify:Have you ever had local anesthetic? Yes NoFemales: Are you pregnant? Yes NoPATIENT CERTIFICATION/APPROVAL & CONSENT:I, the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.Patient (Signature)DateI agree that typing my name above constitutes my legal electronic signature. I agree that typing my name above constitutes my legal electronic signature.(FOR MINORS UNDER 18 YEARS)PATIENT (GUARDIAN) CERTIFICATION/APPROVAL & CONSENTI, the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated, and I will assume responsibility for fees associated with these procedures.Parent/Guardian (Signature)DateI agree that typing my name above constitutes my legal electronic signature. I agree that typing my name above constitutes my legal electronic signature.Submit New Patients Form
