New Patient Medical History

Confidential Medical & Dental History

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Within the past year, have there been any changes in your general health?(Required)
What is the date (or approximate date) of your last medical exam?
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When was your last dental visit?
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WOMEN ONLY: Are you pregnant?(Required)

Please mark any of the following to indicate Yes in response to the question:
Do you grind your teeth (either consciously or during sleep)?(Required)
Do you currently have any dental implants, dentures, or partials?(Required)
Have you ever had complications following dental treatment?(Required)
Are you currently under the care of a physician due to a specific condition?(Required)
Have you been hospitalized within the last 5 years due to a surgery or illness?(Required)
Do you use tobacco (smoking or chewing)?(Required)
Do you have Dental anxiety?(Required)

Please 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:
Allergy(Required)
AIDS/HIV(Required)
Alcohol or chemical dependency(Required)
Arthritis or Rheumatism(Required)
Artificial joints or valves(Required)
Asthma(Required)
Blood transfusion(Required)
Cancer/radiotherapy/chemotherapy(Required)
Contraceptive use(Required)
Diabetes(Required)
Eating disorders(Required)
Epilepsy/seizures(Required)
Fainting/dizzy spells(Required)
Heart disease(Required)
High/low blood pressure(Required)
Hyper/hypo glycaemia(Required)
Kidney disease(Required)
Excess bleeding(Required)
Liver disease (Hepatitis/Jaundice)(Required)
Lung disease/chest pains /Stroke(Required)
Tuberculosis(Required)
Mental or Nervous disorder(Required)
Venereal/communicable disease(Required)
Stomach ulcers(Required)
Sleep apnea(Required)

Are you currently taking any kind of medication? If YES, please specify:
Do you have any other illnesses or conditions not mentioned above?

Is there any other family you would like to be seen? If so, please list below:

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.

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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. Vancouver Dental Specialty Clinic takes no responsibility for web communication.

3488 West Broadway

Vancouver, BC, V6R 2B3

604-336-0958

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