1: Are you being treated for any medical condition at the present or have you been treated within the last year?

Yes

Not Sure

2: Has there been any change in your general health in the past year?

Yes

Not Sure

3: When was your last medical checkup?

4: Do you have any condition that could affect your immune system e.g. leukemia, HIV infection +/- tested, lupus?

Yes

Not Sure

5: Are you undergoing any therapies that could affect your immune system e.g. radiotherapy or chemotherapy?

Yes

Not Sure

6: Are you currently taking any steroids or cortisone?

Yes

Not Sure

7: Do you ankles, feet or hands swell?

Yes

Not Sure

8: Are you allergic to any medications?

Yes

Not Sure

9: Are you allergic to any of the following?

10: Are you allergic to any foods?

Yes

Not Sure

11: Do you have any other allergies that we should be aware of?

Yes

Not Sure

12: Have you ever had any peculiar or adverse reactions to any medicines or injections?

Yes

Not Sure

13: Are you taking or have you ever taken osteoporosis medications (e.g. Fosamax, Actonel)?

I am currently taking

I was previously taking but am no longer

Not sure

14: Are you currently taking any prescription Medications?

Yes

Yes and I brought a list

Not Sure

15: Have you been advised against taking any medications?

Yes

Not Sure

16: Are you taking any non-prescription drugs?

Yes

Yes and I brought a list

No Sure

17: Do you take any recreational drugs on a regular basis?

Yes

Not Sure

18: Are you taking any herbal supplements of any kind?

Yes

Yes and I brought a list

Not Sure

19: Do you have Diabetes?

I have Type 1 Diabetes

I have Type 2 Diabetes

Not Sure

20: Do you have or have you ever had any of the following?

21: Do you have or have you had any conditions or diseases not previously listed that we should be aware of?

Yes

Not Sure

22: Are there any diseases or medical problems that run in your family?

23: Do you have a bleeding problem or bleeding disorder?

Yes

Not Sure

24: Do you have or have you ever had a replacement or repair of a heart valve or stent?

Yes

Not Sure

25: Do you have or have you ever had an infection of the heart (e.g. infective endocarditis)?

Yes

Not Sure

26: Have you had a transplant (Heart, Lung, Organs)?

Yes

Not Sure

27: Do you have a Heart condition from birth (e.g. congenital heart disease/lesions)?

Yes

Not Sure

28: Do yo have or have you ever had any heart or blood pressure problems?

Yes

Not Sure

29: Do you have a prosthetic or artificial joint?

Yes

Not Sure

30: Have you ever been hospitalized for any illnesses or operations?

Yes

Not Sure

31: Have you ever had any injury or surgery to your face or jaws?

Yes

Not Sure

32: Do you smoke or chew tobacco products?

Yes

Not Sure

33: Are you nervous during dental treatment?

Yes

not Sure

34: Is there anything else about your health we should be made aware or?

Yes

Not Sure

35: Do you wish to speak to the doctor privately about any problem or medical condition?

Yes

Not Sure

36: Has the child patient recently had any of the following?

37: Are there any immunizations that the child is not up to date with?

Yes

Not Sure

...For Women only...

38: For Woman only: Are you breastfeeding?

Yes

No/ Not applicable

39: For woman only: Are you pregnant?

Yes

No/Not applicable

Not Sure

Have you ever had a complete dental examination with a full series of dental x-rays within the past 3 years?

Yes

Have you ever had any of the following dental treatments?

Have you had any extractions?

Yes

If yes, did you experience prolonged bleeding after?

Yes

Are you aware of bad breath or a bad taste in your mouth?

Yes

Have you ever had a bad experience at the dentist?

Yes

What is your present dental problem?

PATIENT/GUARDIAN APPROVAL AND CONSENT

I, the undersigned, certify that all of the above medical and dental information is true to my knowledge and I have not omitted any pertinent information.

I also consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic as indicated, and I will assume the responsibility for fees associated with these procedures.

New Patient Office Policy Agreement

I consent to this office, Harmony Dental Studio, to collect, use and disclose information about me for the following purposes:

1:To assess your health needs and to deliver safe, efficient patient care

2:To ensure continuously high quality services.

3:To advice you of treatment options.

4:To offer and provide treatment, care and services in relationship to the oral and maxillofacial complex, and general dental care.

5:To allow is to efficiently follow-up for treatment, care and billing.

Staying in Contact:

1:To enable us to contact you.

2:To establish and maintain communication with you to distribute health-care information, and to book and confirm appointments.

Insurance Claims and Submissions:

1:To complete and submit electronic and/or paper dental claims for third party adjudication, pre-approval where necessary.

2:I authorize the release of my Dental Benefits Plan information, contained in claims and estimates submitted electronically, or by mail. This authorization shall continue to be in effect until contractually terminated by the account holder.

Patient Account:

1:To send invoices for goods and services.

2:To process payments.

3:If patient accounts fall into arrears, all reasonable collection fees will be the responsibility of the patient, in addition to the arrears.

1:For teaching and demonstrating the purposes on an anonymous basis.

2:To permit potential Dentists, practice brokers, and/or advisors to evaluate the dental practice and conduct an audit.

Cancelled, Missed, or Rescheduled Appointments:

1:I am aware that there may be a $50.00 charge when cancelling/rescheduling an appointment with less than 2 (two) business days notice.

2:I am aware that there may be a $50.00 charge when an appointment is missed.

I agree to terms & conditions provided by the Harmony Dental Studio.

Print Your / Guardian Name *

Patient or Guardian's Signature *

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