Patient Information Form

Patient Name*

First Last

Nickname/Preferred Name:

Date Of Birth:*

YYYY

MM

DD

Primary Phone Number:*

This is a:*

Home Phone
Cell Phone

Please 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 Phone

Email Address:*

Home Address / Mailing Address:*

Street Address Address Line 2 City Province Postal Code

Name of Physician(s) and their Specialty:

Doctor's Name Specialty

What is your estimate of your general health?*

Excellent
Good
Fair
Poor

Have you ever been hospitalized for an illness or injury?*

Yes
No

If yes, reason for hospitalization and estimated date:

Have you ever had an allergic or bad reaction to the following (please check):*

DO YOU HAVE or HAVE YOU HAD (please check if applicable):*

Please provide more details:

ARE YOU:*

Presently being treated for any other illness?
Taking dietary supplements?
Often exhausted or fatigued
Experiencing frequent headaches
A smoker, smoked previously or use vapes
Taking birth control
Currently pregnant
Currently breast feeding
I do not have any of the above conditions / they do not apply to me

Please provide more information:

Please 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, or vitamins?*

Yes
No

List all medications, supplements or vitamins being taken (Include drug name, dosage, and purpose for taking it):

Dental History

Previous 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)?

YYYY

MM

DD

I routinely see my dentist every:

On a scale of 1 to 10, how fearful of dental treatment are you, where 1 is not fearful and 10 is very fearful:

Have you had an unfavourable dental experience?

Yes
No

Have you ever had complications from past dental treatment?

Yes
No

Have you ever had any trouble getting numb or had any reactions to local anesthesia?

Yes
No

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes
No

Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

Yes
No

Gum And Bone

Do your gums bleed sometimes or are they ever painful when brushing or flossing?

Yes
No

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes
No

Have you ever noticed an unpleasant taste or odor in your mouth?

Yes
No

Is there anyone with a history of periodontal disease in your family?

Yes
No

Have you ever experienced gum recession, or can you see more of the roots of your teeth?

Yes
No

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes
No

Have you ever experienced a burning or painful sensation in your mouth not related to your teeth?

Yes
No

Tooth Structure

Have you ever had any cavities within the last 3 years?

Yes
No

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes
No

Do you feel or notice any holes (ie. craters) on the biting surface of your teeth?

Yes
No

Are any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth?

Yes
No

Do you have any grooves or notches on your teeth near the gum line?

Yes
No

Have you ever chipped teeth, broken teeth or had a cracked filling?

Yes
No

Do you frequently get food trapped between any teeth?

Yes
No

Bite And Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes
No

Do you clench or grind your teeth during the day?

Yes
No

Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

Yes
No

Do you wear or have you ever worn a bite appliance or night guard?

Yes
No

Smile Characteristics

Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? If so please explain:

Have you ever whitened your teeth?

Yes
No

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes
No

Have you been disappointed with the appearance of previous dental work?

Yes
No

Personal Information Patient Consent

At 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 files
To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts
To process claims for payment or reimbursement from third-party health benefit providers and insurance companies
To allow us to maintain communication and contact with you to discuss health care information and to book and confirm any appointments
To send patients informational material about our dental practice

All 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*

YYYY

MM

DD

Name

First Last

Signature*