New Patients Form

New Patients

Title:

First Name:

Last Name:

DATE OF BIRTH (D/M/Y):

DD slash MM slash YYYY

Age:

Gender

Male

Female

Other

Phone (Home)

Phone (Cell)

Phone (Work)

Home Address:

City :

App/Unit

Province:

Postal Code:

Occupation:

Employer:

Health card number:

Name of Family Doctor:

Phone:

Address:

Name of your Specialist:

Phone:

Address:

In case of EMERGENCY, We should notify:

Name:

Relationship:

Phone:

How did you hear about us?

Google

Facebook

Instagram

Website

Radio

Newspaper

Signage

Postcard or Flyer

Friend

Family

Other

*May we send you emails about important office notification, including appointment reminders?

Yes

Insurance Information

Primary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

DD slash MM slash YYYY

Policy holder Contact Phone Number:

Group Policy/plan Number:

I.D./Certificate Number:

Marital Status:

Single

Married/Common Law

Other

Insurance Company Name:

Secondary Insurance Company Information

Name of Insurance Policy Holder:

Date of Birth:

DD slash MM slash YYYY

Policy holder Contact Phone Number:

Group Policy/plan Number:

I.D./Certificate Number:

Marital Status:

Single

Married/Common Law

Other

Insurance Company Name:

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.

Do you have or have you ever had any of the following:

Heart condition

Angina (Chest Pain)

Heart surgery/procedures

Heart attack

Stroke/T.I.A

Heart murmur

Mitral valve prolapse

Congenital heart disease

Infective Endocarditis

Pacemaker

High blood pressure

Low blood pressure

General Anesthetic complications

Diabetes: Type l or ll

Hypolglycemia

Rheumatic fever

HIV positive/AIDS

Leukemia

Anemia

Blood disorders

Hepatitis A/B/C

Hemophilia

Excessive bleeding/bruising

Immunedeficiencies

Eating disorder

Lupus

Thyroid disease

Kidney disease

Liver disease

HPV

Herpes/Cold sores

Physical impairment

Cancer

Asthma

Respiratory conditions

Lung disease

Tuberculosis

Snoring/sleep apnea

Dizziness/fainting

Ulcers/acid reflux

Intestinal/stomach problems

Above average weight gain/loss

COVID-19

Vision Impairment

Hearing impairment

TMJ (jaw joint) concerns

Arthritis

Joint Replacement

Osteoperosis

Epilepsy/seizures

Cognitive impairment

Depression

Anxiety

Mental health issues

Drug/alcohol dependency

Tobacco Use

Other

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

Yes

Not Sure

Please explain

Do you have any allergies or sensitivities to any:

Medications:

Latex/rubber products:

Other: (e .g . hay fever, seasonal/environmental, foods):

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

Yes

Not Sure

please list them:

Has your physician ever told you to take antibiotics prior to dental procdure?

Yes

Not Sure

please mention the reason for antibiotic:

Have you ever experienced complications following a medical or dental procedure?

Yes

Are you currently being treated for any medical condition or have you been treated within the past year?

Yes

Not Sure

please explain?

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

Not Sure

please explain:

Have you ever been hospitalized for any illnesses or operations?

Yes

please explain:

Do you identify as a patient with a disability?

Yes

Are you Pregnant?

Yes

Not Sure

what is the expected delivery date?

Are you breastfeeding?

Yes

Do you smoke or chew tobacco products?

Yes

please indicate how many and for how long?

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

Yes

please explain:

To the best of my knowledge, the above information is correct.

Patient/Parent/Guardian Signature:

Date

DD slash MM slash YYYY

Dentist Notes:

Dentist Name:

Dentist Signature:

Date

DD slash MM slash YYYY

Dental History Questionnaire

NAME:

1 . What is the reason for your visit today? Are you currently experiencing any dental problems?

2 . Have you been seeing a dentist regularly?

Yes

why not?

3 . Are you nervous during dental visits?

Yes

4 . Have you had a bad experience or complications during dental treatment?

Yes

5.1. When was your last dental visit?

5.2. What was done at that appointment?

6.1. How often do you brush your teeth?

6.2. How often do you floss?

7. Do your gums bleed when you brush or floss?

Yes

Not Sure

8 . Do you feel that you have bad breath?

Yes

Not Sure

9 . Are you happy with the appearance of your teeth?

Yes

10 . Are you happy with your smile?

Yes

11.1. Have you ever whitened your teeth?

Yes

11.2. Are you interested in whitening?

Yes

12 . Is there anything about the appearance of your teeth that you would like to change?

Yes

please explain:

13 . Are you self conscious about your teeth?

Yes

14 . Do you have any problems with your jaw (clicking, limited movement, pain)?

Yes

Not Sure

15 . Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?

Yes

16 . What is the most important thing to you about your future smile and dental health?

I hereby authorize White Canvas Dentistry, Dr. Enas Jabar and associates or assistants as they may designate to perform the dental procedures as may be deemed necessary or advisable or to maintain my dental health or the dental health of any minor or other individual for which I have responsibility, including arrangement and/or administration of any sedation (including nitrous oxide) analgesic, therapeutic, and/or other pharmaceutical agent(s) including related to restorative, palliative, therapeutic or surgical treatments.
I understand that the administration of local anesthetics may cause untoward reaction or side effects, which may include but not limited to, bruising, hematoma, cardiac stimulation, muscle soreness, and temporary, or rarely, permanent numbness. I understand that rarely needles break and my require surgical retrieval.
I understand that as part of dental treatment, including preventive procedures such as cleanings and basic dentistry including fillings of all types, teeth may remain sensitive or even possibly quite painful both during and after completing of treatment. After lengthy appointments, jaw muscle may also be sore or tender. Gums and surrounding tissues may also be sensitive or painful during and/or after treatment. Although rare, it is possible for the tongue, cheek, or other oral tissues of the mouth to inadvertently abraded or lacerated during routine dental procedures. In some cases, sutures of additional treatment may be required.
I understand that as part of dental treatment, items including, but not limited to, crowns, small dental instruments, drills components etc. may be aspirated (inhaled into the respiration) or swallowed. This unusual situation may require a series of x-rays to be taken by a physician or hospital and may, in rare cases, require a bronchoscope or other procedures to ensure safe removal.
I do voluntarily assume all possible risks, including the risk of substantial and serious harm, if any that may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of the minor child or ward. I acknowledge that the nature and purpose of the forgoing procedures have been explained to me if necessary and that I have been given the opportunity to ask questions.
To the best of my knowledge, the above information is correct:

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature:

Date

DD slash MM slash YYYY

contact us

Monday	10:00 am – 7:00 pm
Tuesday	10:00 am – 7:00 pm
Wednesday	10:00 am – 7:00 pm
Thursday	10:00 am – 7:00 pm
Friday	10:00 am – 7:00 pm
Saturday	10:00 am – 6:00 pm
Sunday	Closed