New Patient Registration | Form New PatientPERSONAL INFORMATIONFirst NameLast NameStatus Single Married Child Other Date of BirthHome AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweEmailWork TelHome TelPhysicianPrevious DentistWhy have you decided to change dental offices?How did you hear about us? INSURANCE INFORMATIONName of insured if different from above:EmployerDate of Birth of InsuredInsurance CompanyPolicy/GroupDivision (If applicable):Certificate ID#: Division (If applicable):Do you have Secondary Insurance? Yes NoEMERGENCY CONTACT NameRelationship: Tel:MEDICAL HISTORYAre you being treated for any medical condition at the present or have you been treated within the last year? If yes, specify: Yes NoPlease SpecifyWhen was your last medical check-up?Has there been any change in your general health in the past year?Are you taking any medications or non-prescription drugs of any kind? If yes, please list them below:Do you have any allergies?Have you had an unusual reaction to any drugs or medicines? Penicillin Sulfonamide Aspirin Codein Local AnestheticHave you taken Oral/ IV Bisphosphonates medications? or are you still taking them?Do you have a bleeding problem or bruise easily? Are you on blood thinner?Do you have any conditions that could affect your immune system ego AIDS, HIV infection, Leukemia etc?Do you smoke? If yes, how much?Have you ever been hospitalized for any serious illnesses or operations?Do you have or have you ever had any of the following? Chest Pain/Angina Heart Attack High Blood Pressure Emphysema Asthma Epilepsy Thyroid Disease Kidney Disease Cancer Chemotherapy/Radiation Psychiatric Disorder Tuberculosis Arthritis Steriods Cortisone Stomach Ulcers Diabetes Drug/Alcohol Dependency Stroke Sinus Problems Organ Transplant Heart Murmur Mitral Valve Prolapse Pacemaker Jaundice Hepatitis Liver Disease Prosthetic Joints Artificial Joints Rheumatic FeverFor females: Are you pregnant or breast feeding? Any other conditions or problems of which the dentist should be aware of? If yes, please list: _Have you ever experienced any of the following jaw problems?Pain in your jaw joints, around your ear, orside of your face? Yes NoPopping/clicking in your jaw joints? Yes NoA bite plate or any other appliance? Yes NoDifficulty in opening or closing? Yes NoPain or difficulty while chewing? Yes NoDo you have any of the following habits?Clenching or grinding your teeth while awake or asleep? Yes NoBiting your cheeks or lips? Yes NoMouth breathing while awake or asleep? Yes NoPlacing foreign objects in your mouth (pencils, nails, pipes, pins, fingernails)? Yes NoHave you ever had any of the following?Periodontal Treatment? (treatment of the gums) Yes NoOrthodontic Treatment? (to straighten or realign teeth) Yes NoA bite plate or any other appliance? Yes No Your bite plate or any other appliance? Yes NoWhen was your last dental visit?When did you last have dental x-rays?How often do you brush your teeth?How often do you floss your teeth?Have you been seeing a dentist regularly? Yes NoDo any of your teeth ache? Yes NoHave you ever been advised to take antibiotics before dental appointments? Yes NoDo your gums bleed when you brush? Yes NoDo you have any pain when you chew? Yes NoDo you feel that you have bad breath? Yes NoHave you ever been in a motor vehicle accident or experienced any blows to your jaw? Yes NoHave you ever had a dental implant surgery? Yes NoIf yes, who performed the surgery and when was it done? Yes NoAre you being followed-up by a dental specialist? Yes NoPlease list anything else not mentioned above regarding your past dental history: Yes NoINFORMED CONSENT FOR EXAMINATION, GENERAL AND SPECIFIC I UNDERSTAND that in order to get my examination: You will be asked about medical history, dental history, current and previous, Chief complaint, goals of the treatments. You will disclosethe current accurate information to the best of your knowledge. All information you share is confidential, only necessary information is collected about you. I only share your information with your consent. Storage, retention and destruction of your personal information complies with existing legislation, and privacy. Privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons. Extra oral exam, Intra oral exam, elective Oral cancer screening, TMJ assessment, Dental Occlusion Assessment, Specific Exam, or Secondopinion are all procedures that need the use of sterilized dental instruments that will be used during the exam. You have the right to denyuse of any instruments. You have the right to ask all the questions about different procedures and getting them explained to you beforethey are conducted. Collecting additional information such as, dental casts or impressions, x-ray or other means of imaging, photography, Referral to otherspecialists such as and not limited to: Periodontists, Endodontists, Orthodontists, Oral medicine, Oral anaesthesia, Maxillofacial Surgeonand Physician is needed to formulate accurate diagnoses and you will be informed about them as needed. You have the right to deny anyof those data collections procedures. You authorize photos, slides, and x-rays of my care and treatment during or after its completion to be used for the advancement ofdentistry and for reimbursement purposes. My identity will not be revealed to the general public, however, without my permission. Submit Form CONNECT WITH US (905) 683-3700 info@westajaxdental.ca 2892781759 SOCIAL MEDIA VISIT US West Ajax Dental 73 Old Kingston Rd, Ajax, ONL1T 3A6 HOURS OF OPERATION Monday: 7:30 am - 5:30 pm Tuesday: 10:00 am - 8:00 pm Wednesday: 10:00 am - 8:00 pm Thursday: 7:30 am - 5:30 pm Friday: By Appointment Only Saturday: 9:00 am - 2:00 pm Sunday: Closed
