Welcome to Aqua Dental

Registration Form

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Patient Profile:

First Name: Last Name: Preferred Name:

Address: Address 2:

City: Province: Postal Code:

Home Phone: Work: Ext:

Cell Phone:

Email: Emergency Use only:

Preferred Method of Contact: Home Work Cell Email

Date of Birth: Age: Sex: Male Female

Emergency Contact Name: Tel:

Physician Name: Tel:

Spouse/Partner Name: Tel:

Employment Status: Full Time Part Time Retired Other

Occupation: Employer:

Student Status: N/A Full Time Part Time School

Do you have dental insurance? Yes No
(If yes, see Insurance information box below)

Is the Patient responsible for the account? Yes No
(If no, see responsible Party information box)

Responsible Party for Account

(if someone other than the patient) Parent Guardian Spouse Other

First Name: Last Name:

Address: Address 2:

City: Province: Postal Code:

Home Phone: Work: Ext:

Cell Phone:

Email: Emergency Use only:

Preferred Method of Contact: Home Work Cell Email

Date of Birth:

Insurance Information Primary Insurance

Name of Policy Holder Relationship: Self Spouse Child Other

Policy Holder's Date of Birth: Employer:

Insurance Company: Insurance Company Contact #:

Mailing Address:

City: Province: Postal Code:

Policy/Group #: ID/Certificate #:

Division #:

Secondary Insurance

Name of Policy Holder Relationship: Self Spouse Child Other

Policy Holder's Date of Birth: Employer:

Insurance Company: Insurance Company Contact #:

Mailing Address:

City: Province: Postal Code:

Policy/Group #: ID/Certificate #:

Division #:

Dental History

Name: Date:

Name of Previous dentist/location:

When was your last dental visit?

When was your last dental cleaning?

When were your last dental x-rays?

Whats is your chief concern?

Have you ever had problem with the following?

  • Frequent Headaches
  • Jaw Pain
  • Jaw Clicking
  • Pain Around Ear
  • Head/Neck Muscle Fatigue
  • Head/Neck Trauma/injury
  • Grinding Habits
  • Clenching Habits
  • Sensitivity To Hot
  • Sensitivity To Cold
  • Sensitivity To Air
  • Sensitivity During Dental Cleaning
  • Pain When Biting Down
  • Bad Breath
  • Bad Taste
  • Bleeding Gums
  • Periodontal Problems
  • Loose Teeth
  • Tooth Abscess
  • Food Collection Between Teeth
  • Canker Sores
  • Cold Sores
  • Re-ocurring Sore Spots
  • Pen/object Chewing Habit
  • Nail Biting Habit

Dental Axiety None Mild Moderate Severe

Have you ever had any of the following?

  • Orthodontic Treatment
  • Gum Surgery
  • Oral Surgery

Do you have a family history of Head/Neck/Oral Cancer? Yes No

Do you like your teeth when you smile? Yes No

Do you want whiter teeth? Yes No

Are you interested in Orthodontic treatment in the future ( braces )? Yes No

What would you like to improve about your smile?

What is your current home care routine?

Brush: /Daily

Flossing: /Weekly

Antimicrobial Rinse: /daily

Other:

Do you wear a:

  • Night Guard
  • Sport Guard
  • Orthodontic Retainer
  • Complete Denture
  • Partial Denture

Additional Information:

Medical History

Name: Date:

Although dental personnel primarily treat the area in and around your mouth; your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking could have an important interrelationship with the dentistry you will receive. This information is always kept confidential as per our privacy policy. Thank you for answering the following questions

Are you under a physicians care now? Yes No

Have you ever been hospitalized, treated or had major surgery? Yes No

Have you ever had a serious head or neck injury? Yes No

Are you taking any medication or supplements?
(including prescription, over the counter, or vitamins) Yes No

Have you ever taken Bisphosphonates (ie. Fosomax)? Yes No

Have you ever had a surgery to replace a joint? Yes No

Have you ever been recommended to take antibiotics before a dental appointment Yes No

If yes, please explain:

If yes, please explain:

If yes, please explain:

If yes, please list below in 'Additional Information'

If yes, please explain:

If yes, please explain:

If yes, please explain:

When was your last complete physical? How is your blood sugar level? Normal Border Line High

What was your last blood pressure reading? When was your last Blood Pressure reading?

Women Only:

Please indicate what currently applies to you:

  • Pregnant/trying To Get Pregnant?
  • Talking Oral
  • Nursing

Tobacco Use:

Do you Currently use tobacco? Yes No

Are your habits on/off? Yes No

Have you ever used tobacco Yes No

Do you have future plans to quit? Yes No

If yes, How much daily/weekly?

If yes, please explain:

If yes, How long ago?

Please explain:

Allergies/Reactions

  • Aspirin
  • Penicillin
  • Codeine
  • Acrylic
  • Metal
  • Latex
  • Local Anaesthetic
  • Nitrous Oxide
  • Other

Please indicate if you have any of the following:

  • AIDS/ HIV Positive
  • Excessive Bleeding
  • Mitral Valve Prolapse
  • Acid Reflux
  • Excessive Thirst
  • Osteoporosis
  • Alzheimers Disease
  • Fainting Spells/Dizziness
  • Pain In Jaw Joint
  • Anaphylaxis
  • Frequent Cough
  • Psychiatric Care
  • Anaemia
  • Frequent Headaches
  • Parathyroid Disease
  • Angina
  • Glaucoma
  • Radiation Treatments
  • Anxiety
  • Hay Fever
  • Recent Significant Weight Loss
  • Arthritis/Gout
  • Heart Attack
  • Renal Disease
  • Artificial Heart Valve
  • Heart Murmur
  • Rheumatism
  • Artificial Joint
  • Heart Pacemaker
  • Scarlet Fever
  • Asthma
  • Heart Trouble/Disease
  • Shingles
  • Blood Transfusion
  • Haemophilia
  • Sickle Cell Disease
  • Breathing Problems
  • Heart Burn
  • Sinus Trouble
  • Bruise Easily
  • Hepatitis A Or B
  • Spina Bifida
  • Cancer
  • Hepatitis C Or Other
  • Stomach/Intestinal Disease
  • Chemotherapy
  • Herpes
  • Stroke
  • Chest Pains
  • High Blood Pressure
  • Swelling Of Limbs
  • Convulsions
  • Hives Or Rash
  • Thyroid Disease
  • Cold Sores/Fever Blisters
  • Hypoglycemia
  • Tonsillitis
  • Congenital Heart Disorder
  • Irregular Heartbeat
  • Tuberculosis
  • Cortisone Medication
  • Jaundice
  • Tumours Or Growths
  • Diabetes
  • Kidney Problems
  • Ulcers
  • Drug Addition
  • Leukemia
  • Venereal Disease
  • Easily Winded
  • Liver Disease
  • Emphysema
  • Low Blood Pressure
  • Epilepsy/Seizures
  • Lung Disease

Have you ever had any serious illness not listed above? Yes No If yes, please explain

Are you on a special diet? Yes No If yes, please explain

Do you snore or suffer from sleep apnea? Yes No If yes, please explain

Do you consume alcohol? Yes No If yes, how often

Do you take recreational drugs? Yes No If yes, how often?

Additional Information:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health and the health of others. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, OR GUARDIAN DATE:

Appointment Cancellation Policy

We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient who might be in pain and require urgent care. We value your time so we endeavor to run on schedule. However, late arrivals notonly affect us but the rest of our patients,therefore,late arrivals may result in rescheduled appointments.

Please understand that it is your responsibility to keep track of your appointment. As a courtesy, we contact you prior to your appointment to remind you, but it is ultimately your responsibility to ensure that you will be at your appointment on time.

Our policy is as follows:

Due to continuous high demand in prime appointment times, we require that you give our office 48 business hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office by telephone within the required time, this is considered a missed appointment. A fee starting at $50.00(assessed based on the length of your appointment)will be charged to you; (If a family is booked, that is $50 per person) this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred without the payment of this fee.

In the event that you do not show up for your scheduled appointment twice, we will be happy to assist you in transferring your records to the office of your choice with a letter explaining why the transfer has been made.

Additionally, if you are more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $50.00 cancellation fee will be charged.

If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have.

We thank you for your understanding.

I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

I, (print name), have received a copy of Aqua Dental Appointment Cancellation Policy.

Signature of Patient: Date: