Confidential Medical & Dental HistoryFirst Name(Required)MiddleLast Name(Required)Preferred NameBirth Date(Required) YYYY dash MM dash DD Phone Home(Required)Phone Mobile(Required)Email(Required) Street Address(Required)City(Required)Province(Required)Postal Code(Required)What is your chief dental concern today?(Required)Occupation(Required)Whom may we thank for reffering you to our office?Within the past year, have there been any changes in your general health?(Required) Yes NoWhat is the date (or approximate date) of your last medical exam?Date(Required) YYYY dash MM dash DD When was your last dental visit?Date(Required) YYYY dash MM dash DD Your Primary Care Physician's Name(Required)Your Primary Care Physician's AddressPCP Phone(Required)WOMEN ONLY: Are you pregnant?(Required) Yes NoPlease mark any of the following to indicate Yes in response to the question:Do you grind your teeth (either consciously or during sleep)?(Required) Yes NoDo you currently have any dental implants, dentures, or partials?(Required) Yes NoHave you ever had complications following dental treatment?(Required) Yes NoAre you currently under the care of a physician due to a specific condition?(Required) Yes NoHave you been hospitalized within the last 5 years due to a surgery or illness?(Required) Yes NoDo you use tobacco (smoking or chewing)?(Required) Yes NoDo you have Dental anxiety?(Required) Yes NoPlease mark any of the following to indicate Yes in response to the question: Please indicate if you have experienced or presently have any of the following:UntitledAllergy(Required) Yes NoAIDS/HIV(Required) Yes NoAlcohol or chemical dependency(Required) Yes NoArthritis or Rheumatism(Required) Yes NoArtificial joints or valves(Required) Yes NoAsthma(Required) Yes NoBlood transfusion(Required) Yes NoCancer/radiotherapy/chemotherapy(Required) Yes NoContraceptive use(Required) Yes NoDiabetes(Required) Yes NoEating disorders(Required) Yes NoEpilepsy/seizures(Required) Yes NoFainting/dizzy spells(Required) Yes NoHeart disease(Required) Yes NoHigh/low blood pressure(Required) Yes NoHyper/hypo glycaemia(Required) Yes NoKidney disease(Required) Yes NoExcess bleeding(Required) Yes NoLiver disease (Hepatitis/Jaundice)(Required) Yes NoLung disease/chest pains /Stroke(Required) Yes NoTuberculosis(Required) Yes NoMental or Nervous disorder(Required) Yes NoVenereal/communicable disease(Required) Yes NoStomach ulcers(Required) Yes NoSleep apnea(Required) Yes NoDo you have any other health issues, conditions, disease or allergies?Are you currently taking any kind of medication? If YES, please specify:DrugReasonDrugReasonDrugReasonDo you have any other illnesses or conditions not mentioned above?If YES, please specify:Emergency Contact's Name(Required)Emergency Contact's AddressEC Phone(Required)Is there any other family you would like to be seen? If so, please list below:Relative's NameRelative's RelationshipConsent Checkbox 1(Required) I consent to have radiographic images taken for diagnostic purposes.(Required)Consent Checkbox 2(Required) To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail. (Required)Cancellation policy(Required) CANCELLATION POLICY: (Required) Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the dentist’s day that another patient could have filled. As such, we require three (3) business days' notice for any cancellations or changes to your appointment. Patients who provide less than three (3) business days' notice or miss their appointment will be charged a late cancellation fee of $150.Authorization:I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential to be hazardous to my health.I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.I authorize the dentist to release any information, including the diagnosis and records of treatment or examination for myself and my dependent(s), to third-party insurance carriers, payors, and/or healthcare practitioners.I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).I understand that my dental office will submit claim forms and pre-authorization forms to my insurance on my behalf, but it is my responsibility to be aware of/update the dental office on any changes to my coverage.I acknowledge that most insurance providers will send all correspondence to me directly, and my dental office is unable to see the outcome of claims or pre-authorizations to confirm my coverage.I acknowledge that most insurance providers will send all correspondence to me directly, and my dental office is unable to see the outcome of claims or pre-authorizations to confirm my coverage.I understand that if I have concerns with my coverage, I will need to discuss this with my insurance provider directly.Who is signing?Patient's SignParent's SignGuardian's SignDate:(Required) YYYY dash MM dash DD Draw Your Signature(Required)By entering your full name, email address, and phone number, you agree with online transfer of information that will be used by Vancouver Dental Specialty Clinic for the sole purpose of returning your request to be contacted by us. 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