Patient Information FormPatient Information FormStep 1 of 616%Patient Name* First Last Nickname/Preferred Name:Gender Male Female OtherDate Of Birth:* Year Month Day Referred by:Primary Phone Number:*This is a:* Home Phone Cell PhonePlease Note: Our office uses text message reminders that can only be sent to cell phones. If you do not use a cell phone, we can send reminders via email.Secondary Phone Number:This Is A: Home Phone Cell PhoneEmail Address:* Home Address / Mailing Address:* Street Address Address Line 2 City Province ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Name of Physician(s) and their Specialty: Doctor's Name Specialty Doctor's Name Specialty Doctor's Name Specialty What is your estimate of your general health?* Excellent Good Fair PoorHave you ever been hospitalized for an illness or injury?* Yes NoIf yes, reason for hospitalization, estimated date, and any complications experienced:Have you ever had an allergic or bad reaction to the following (please check):Aspirin AspirinType of reaction that occurred? Approximate date of reaction?NSAIDs (e.g. Ibuprofen, Naproxen) NSAIDs (e.g. Ibuprofen, Naproxen)Type of reaction that occurred? Approximate date of reaction?Acetaminophen (i.e. Tylenol) Acetaminophen (i.e. Tylenol)Type of reaction that occurred? Approximate date of reaction?Codeine CodeineType of reaction that occurred? Approximate date of reaction?Penicillin PenicillinType of reaction that occurred? Approximate date of reaction?Erythromycin ErythromycinType of reaction that occurred? Approximate date of reaction?Clindamycin ClindamycinType of reaction that occurred? Approximate date of reaction?Tetracycline TetracyclineType of reaction that occurred? Approximate date of reaction?Sulfa SulfaType of reaction that occurred? Approximate date of reaction?Local anesthetic Local anestheticType of reaction that occurred? Approximate date of reaction?Fluoride FluorideType of reaction that occurred? Approximate date of reaction?Chlorhexidine ChlorhexidineType of reaction that occurred? Approximate date of reaction?Metals (e.g. nickel) Metals (e.g. nickel)Type of reaction that occurred? Approximate date of reaction?Latex LatexType of reaction that occurred? Approximate date of reaction?Nuts NutsType of reaction that occurred? Approximate date of reaction?Fruit FruitType of reaction that occurred? Approximate date of reaction?Other OtherType of reaction that occurred? Approximate date of reaction?I have not had allergic/bad reactions I have not had allergic/bad reactionsDO YOU HAVE or HAVE YOU HAD (please check if applicable):Chest pain / angina Chest pain / anginaDate diagnosed? How often do you experience chest pain / angina? Any precipitating factors? Duration of pain? What relieves the pain (ie nitroglycerin)? Any specialist treating this condition?High blood pressure High blood pressureDate diagnosed? Current treatment? Which doctor is treating this condition?Low blood pressure Low blood pressureDate diagnosed? Current treatment? Which doctor is treating this condition?High cholesterol High cholesterolDate diagnosed? Current treatment? Which doctor is treating this condition?History of infective endocarditis History of infective endocarditisDate diagnosed? Do you see a specialist and how often?Congenital heart defect (heart problem from birth) Congenital heart defect (heart problem from birth)Type and date diagnosed? Do you see a specialist and how often?Artificial heart valves or repair to valve Artificial heart valves or repair to valveDate of surgery? Do you see a specialist and how often?Heart attack / MI Heart attack / MIDate(s) diagnosed? Treatment (past or present)? Do you see a specialist and how often?Arrhythmia (e.g. irregular heart beat, atrial fibrillation) Arrhythmia (e.g. irregular heart beat, atrial fibrillation)Type and date diagnosed? Treatment (past or present)? Do you see a specialist and how often?Congestive heart failure Congestive heart failureDate diagnosed? Treatment (past or present)? Do you see a specialist and how often?Any heart conditions, heart surgery, or heart infections? Any heart conditions, heart surgery, or heart infections?What type of heart condition / infection do or did you have? Date diagnosed? What type of heart surgery did you have? Date of heart surgery and any complications experienced? Any specialist treating your condition(s)?Stroke (CVA) Stroke (CVA)Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?TIA (transient ischemic attack) TIA (transient ischemic attack)Date(s) diagnosed? Any type of treatment (current or past)? Do you see a specialist and how often? Any residual effects?Pacemaker PacemakerDate inserted? Type of pacemaker? Do you see a specialist and how often?Implanted defibrillator (ICD) Implanted defibrillator (ICD)Date inserted? Do you see a specialist and how often?Epilepsy / seizures Epilepsy / seizuresType? Date diagnosed? Treating doctor or specialist? Triggers? Frequency? Date of last episode? Any treatment (past or present)? Any hospitalizations?Asthma AsthmaDate diagnosed? Frequency of attacks? Severity of attacks (ie any hospitalizations)? Date of last attack? Triggers for the attacks (e.g. exercise, emotional upset, anxiety, stress)? Treatment (and how effective is the treatment)? Which doctor is treating this condition?Bronchitis BronchitisDate(s) diagnosed? Treatment received? Which doctor is treating this condition?Any breathing problems (COPD, Emphysema, Shortness of breath) Any breathing problems (COPD, Emphysema, Shortness of breath)Type? Date diagnosed? Treatment received? Which doctor is treating this condition?Sleep Apnea Sleep ApneaDate diagnosed? Treatment received? Which doctor is treating this condition?Diabetes DiabetesDate diagnosed? Type of diabetes (1 vs 2)? Treatment (e.g. diet/ exercise, oral medications, and/or insulin)? Presence of complications (e.g. neuropathy, cardiac disease)? Which doctor is treating this condition? Most recent hemoglobin A1c level? Most recent blood glucose (blood sugar) level (fasting or non fasting)?Hypothyroidism HypothyroidismDate of diagnosis? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hyperthyroidism HyperthyroidismDate of diagnosis? Treatment (past or present)? Note: if radiation treatment was it radioactive iodine or external beam radiation? Current medication / any recent changes in dosage? Which doctor is treating this condition?Hormone deficiency or imbalance Hormone deficiency or imbalanceType? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Acid reflux / GERD Acid reflux / GERDDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Stomach ulcerations Stomach ulcerationsDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Digestive disorder (e.g. Celiac disease) Digestive disorder (e.g. Celiac disease)Type? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Liver problems (e.g. liver disease, cirrhosis, hepatitis) Liver problems (e.g. liver disease, cirrhosis, hepatitis)Type? Date diagnosed? Which doctor is treating this condition? Current status? Treatment (past or present)? Any known liver damage? Any known bleeding problems?Kidney disease Kidney diseaseType? Date diagnosed? Treatment (past or present)? Which doctor is treating this condition?Sexually transmitted disease (e.g. HPV) Sexually transmitted disease (e.g. HPV)Type? Date diagnosed? Which doctor is treating this condition?HIV / AIDS HIV / AIDSDate diagnosed? Last CD4 count? Viral load if known? Treatment (past or present)? Which doctor is treating this condition?Prosthetic joint Prosthetic jointWhich joint(s)? Month / year replaced? Any complications with the replacement (i.e. any infections)? Did the orthopedic surgeon recommend antibiotics before dental care?Arthritis (osteo or rheumatoid) Arthritis (osteo or rheumatoid)Type (osteoarthritis or rheumatoid)? Date diagnosed? Which joints affected? Treatment (past or present)? Which doctor is treating this condition?Osteopenia OsteopeniaDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates) Osteoporosis or ever taken antiresorptive medications (i.e. bisphosphonates)Date diagnosed? Name of medication? Medication taken orally or intravenously? Dosage / frequency of medication? Which doctor is treating this condition?Head or neck injuries Head or neck injuriesType of injury and approximate date(s)? Treatment (past or present)?Neurologic disorders (e.g. Alzheimer’s disease, dementia) Neurologic disorders (e.g. Alzheimer’s disease, dementia)Type? Date diagnosed? Which doctor is treating this condition?Concentration problems or ADD/ADHD Concentration problems or ADD/ADHDDate diagnosed? Which doctor is treating this condition?Major depression Major depressionDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Anxiety disorders Anxiety disordersDate diagnosed? Treatment (past or present)? Which doctor is treating this condition?Bipolar disorder / schizophrenia / panic disorder / eating disorder Bipolar disorder / schizophrenia / panic disorder / eating disorderDiagnosis and date of diagnosis? Treatment (past or present)? Which doctor is treating this condition?Any bleeding problems Any bleeding problemsType of bleeding problem? Treatment (past or present)? Which doctor is treating this condition?Taking blood thinners Taking blood thinnersAnemia AnemiaDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Any problems with your immune system or take drugs that affect your immune system Any problems with your immune system or take drugs that affect your immune systemPlease provide more detail:Cancer CancerType of cancer? Date of diagnosis? Type / date of treatment, including when it finished? Follow up and future planned therapy? Current status of the disease? Which doctor is treating this disease?Chemotherapy ChemotherapyRadiation therapy Radiation therapyTaking steroids Taking steroidsReason for taking steroids?Tumour / abnormal growth Tumour / abnormal growthDiagnosis? Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Chronic ear infections Chronic ear infectionsTreatment (past or present)? Which doctor is treating this condition?Chronic sinus infections Chronic sinus infectionsTreatment (past or present)? Which doctor is treating this condition?Vertigo VertigoDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Alcohol Use Disorder Alcohol Use DisorderDatę diagnosed? Treatment (past or present)? Which doctor is treating this condition?Drug Addiction (Substance Use Disorder) Drug Addiction (Substance Use Disorder)Datę diagnosed? Treatment (past or present)? Which doctor is treating this condition?I confirm I have not had any of the conditions to my knowledge I confirm I have not had any of the above conditions to my knowledgeARE YOU:Presently being treated for any other illness or medical condition (not listed above)? Presently being treated for any other illness or medical condition (not listed above)?Please provide more detail:Often exhausted or fatigued Often exhausted or fatiguedExperiencing frequent headaches or chronic pain Experiencing frequent headaches or chronic painPlease provide more detail:A smoker or vape user A smoker or vape userWhen did you start smoking / vaping? Approximately how often & how much do you smoke or vape?A previous smoker or vape user A previous smoker or vape userWhen did you start & stop smoking / vaping? Approximately how often & how much did you use to smoke or vape?Taking birth control Taking birth controlCurrently pregnant Currently pregnantWhat is your due date? Any complications experienced?Currently breastfeeding Currently breastfeedingI do not have any of the above conditions / they do not apply to me I do not have any of the above conditions / they do not apply to mePlease list any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment:Are you presently taking any medications, supplements, vitamins, and/or probiotics?* Yes NoList all medications, supplements, vitamins, and/or probiotics being taken (Include drug name, dosage, and purpose for taking it):Dental HistoryPrevious Dentist's Name: Doctor's Name Previous Dentist's Phone Number:How Long Were You A Patient?Do you have any specific dental concerns (please list):When Was Your Last Dental Appointment (Estimate If Necessary)? Year Month Day I routinely see my dentist every: 3 Months 4 Months 6 Months 12 Months Not routinelyOn a scale of 1 to 10, how fearful of dental treatment are you, where 1 is not fearful and 10 is very fearful:12345678910Have you had an unfavourable dental experience? Yes NoHave you ever had complications from past dental treatment? Yes NoHave you ever had any trouble getting numb or had any reactions to local anesthesia? Yes NoDid you ever have braces, orthodontic treatment or had your bite adjusted? Yes NoDo you have any missing teeth that never developed or lost teeth due to injury or facial trauma? Yes NoDo you have any missing teeth (excluding wisdom teeth). Yes NoHow many teeth are you missing, approximately?To Our Patients with InsuranceEach insurance benefit package varies considerably with regard to the different combinations of services included depending on the agreed benefits in place. The treatment options presented to you from our team are based upon our professional judgment and not based on your coverage by a dental benefit plan. As a courtesy to you, our staff may offer to process insurance claims on your behalf and submit a predetermination for any treatment you may require. We will help you in handling insurance queries, processing follow-ups or locating lost claims. No question is too small for you to ask, whether it is about your treatment, benefit plan, or statement. As a friendly reminder please note that your insurance policy is an agreement between you, your third-party health benefit provider(s) and/or the insurance company that provides your benefits. Not all services may be covered by your insurance plan. Any fees not covered by the benefit provider/ insurer are the patient's responsibility. We encourage you to fully understand your individual insurance plan. We cannot guarantee your individual coverage. It is your responsibility to update your information with us if there are any changes with your insurance plan. If you haven’t already provided our team with your insurance information, please send an email to info@henleydental.com with your insurance card/ information, along with the policy holder’s date of birth. Optionally, please see our separate form titled “questions to ask your insurance provider” to obtain a breakdown of your plans coverage.Do You Have Dental Insurance? Yes NoInsurance CompanyPolicy Or Plan #ID or Certificate #Subscriber Name / Date Of BirthPersonal Information Patient ConsentAt Henley Dental, our entire team is committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. All of our privacy protocols comply with privacy legislation, standards of the Royal College of Dental Surgeons of Ontario, and the law. This document summarizes some of the personal information that we collect, use and disclose. In addition to the circumstances described in this form, we also collect, use and disclose personal information when permitted by law according to the provisions of the Regulated Health Professions Act.We collect information from our patients such as names, home addresses, telephone numbers, and e-mail addresses (collectively referred to us “Contact Information”).Contact information is collected and used for the following purposes:To open and update patient filesTo invoice patients for dental services, to process credit card payments, or to collect unpaid accountsTo process claims for payment or reimbursement from third-party health benefit providers and insurance companiesTo allow us to maintain communication and contact with you to discuss health care information and to book and confirm any appointmentsTo send patients informational material about our dental practiceAll financial information is collected for payment processing purposes; it is not shared with third parties without your consent.We collect information from our patients about their mental and physical health, including family health history (Collectively referred to as “Medical Information”) to provide safe health care. Patient’s Medical Information is collected and used for the purpose of diagnosing dental conditions and advising you of treatment options.Patients’ Medical and Contact Information is disclosed:To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf.With the consent of the patient, to other dentists and dental specialists, or to other health care professionals.The storage, retention, and destruction of your personal information complies with existing legislation, and privacy protection protocols I consent to the collection, use and disclosure of my personal information as set out above;Date* Year Month Day Name First Last Signature*Cancellation and Payment PolicyPlease know that appointment times have been reserved especially for you, and any change in the schedule can affect many people.If for any reason you are unable to keep the reserved appointment time, we ask the courtesy of two business days notice to allow us to offer the time to another patient who may be waiting for an opening. Appointments canceled with less than two business days notice may be subject to a cancellation fee.Lastly, I understand that I am fully responsible for all amounts not covered by my third-party health benefit provider(s) and/or insurance company, and are due at the end of my appointment, when services are rendered.For your convenience, Henley Dental accepts the following forms of payments: Cash, Debit, all major Credit Cards (Visa, Mastercard, American Express), and personal cheques.I consent to the above Cancellation and Payment Policy as set out by Henley Dental.Signature*You Are Almost Done! Please click the submit button below to send us your formCAPTCHANewsletter Subscribe to NewsletterURLThis field is for validation purposes and should be left unchanged.
