David Gouett Dentistry ADDRESS:
805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6
TEL: 613-389-8660
EMAIL: reception@davidgouettdentistry.com

NEW PATIENT FORM

Your co-operation in completing this questionnaire is essential to providing you with the highest standard of dental care. All information is strictly confidential.

1. REGISTRATION INFORMATION
THE PATIENT IS AN [Adult / Child / Adult under guardianship]
NAME OF GUARDIAN [Guardian Name]
FIRST NAME [First Name]
LAST NAME [Last Name]
TITLE [Dr. / Mr. / Mrs. / Ms. / Miss.]
PREFERS TO BE CALLED [Preferred Name]
EMPLOYER [Employer Name]
ADDRESS: STREET [Street Address]
ADDRESS 2: STREET [Apt/Suite]
CITY AND PROV/STATE [City], [Province]
ZIP/POSTAL CODE [Postal Code]
REASON FOR TODAY’S VISIT? [Examination / Emergency / Other] | [Other Details]
IS THERE A DENTAL PROBLEM YOU WOULD LIKE TREATED IMMEDIATELY? [Response]
PREFERRED APPT. TIME? [Preferred Time]
HOME PHONE [Home Phone]
CELL PHONE [Cell Phone]
PAGER NO. [Pager No.]
BUS. PHONE [Bus. Phone] Ext: [Ext]
E-MAIL ADDRESS [Email Address]
MAY WE CALL YOU AT WORK? [Yes / No]
PREFERS TO BE CALLED [Location Selection]
OCCUPATION [Occupation]
DATE OF BIRTH (M/D/Y) [MM/DD/YYYY]
AGE [Age]
GENDER AND PRONOUNS [Gender/Pronouns]
MARITAL STATUS [Marital Status]
NAME OF SPOUSE [Spouse Name]
ARE OTHER FAMILY MEMBERS PATIENTS AT OUR OFFICE? [Yes / No] | Names: [Names]
WHOM MAY WE THANK FOR REFERRING YOU? [Referral Name]
FAMILY PHYSICIAN [Physician Name]
PHONE [Physician Phone]
MEDICAL SPECIALIST (IF PRESENTLY UNDER CARE) [Specialist Name]
PHONE [Specialist Phone]
IN CASE OF EMERGENCY, PLEASE CONTACT [Emergency Contact Name]
PHONE [Emergency Contact Phone]
2. FINANCIAL & CREDIT INFORMATION
PERSON RESPONSIBLE FOR ACCOUNT: [Self / Spouse / Other]
NAME: LAST, FIRST [Responsible Name]
HOME PHONE [Home Phone]
DRIVER'S LIC. NO. [DL#]
HEALTH CARD # [Health Card #]
CREDIT CARD NO. [Credit Card No.]
EXPIRY DATE [MM/YY]
PRIMARY DENTAL INSURANCE
SUBSCRIBER'S NAME [Subscriber Name]
D.O.B. [MM/DD/YYYY]
INS. YR. END [Date]
EMP./GRP. POLICY HOLDER [Policy Holder]
INS. CO. [Insurance Co.]
TEL. [Insurance Phone]
GRP./IND. POLICY NO. [Policy No.]
CERT. NO. [Cert No.]
SECONDARY DENTAL INSURANCE
SUBSCRIBER'S NAME [Subscriber Name]
D.O.B. [MM/DD/YYYY]
INS. YR. END [Date]
EMP./GRP. POLICY HOLDER [Policy Holder]
INS. CO. [Insurance Co.]
TEL. [Insurance Phone]
GRP./IND. POLICY NO. [Policy No.]
CERT. NO. [Cert No.]
3. MEDICAL HISTORY QUESTIONS
1. Are you being treated for any medical condition at the present or have you been treated within the last year?
RESPONSE: [Yes / No]
2. Has there been any change in your general health in the past year?
RESPONSE: [Yes / No]
3. When was your last medical checkup?
RESPONSE: [Patient Input]
4. Do you have any conditions that could affect your immune system? (e.g. Leukemia, HIV +/- tested, Lupus)
RESPONSE: [Yes / No]
5. Are you undergoing any therapies that could affect your immune system? (e.g. Radiotherapy or Chemotherapy)
RESPONSE: [Yes / No]
6. Are you currently taking any steroids or cortisone?
RESPONSE: [Yes / No]
7. Do your ankles, feet or hands swell?
RESPONSE: [Yes / No]
8. Are you allergic to any medications?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
9. Are you allergic to any of the following? (Latex, Metal, Rubber, None of the above, Not Sure)
RESPONSE: [Selections]
10. Are you allergic to any foods?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
11. Do you have any other allergies that we should be aware of?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
12. Have you ever had any peculiar or adverse reactions to any medicines or injections?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
13. Are you taking or have you ever taken osteoporosis medications? (e.g. Fosamax, Actonel)
RESPONSE: [I am currently taking / I was previously taking but am no longer / No]
IF CURRENTLY OR PREVIOUSLY TAKING, PLEASE SPECIFY WHICH MEDICATION: [Medication Details]
14. Are you currently taking any prescription medications?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
15. Do you take any recreational drugs on a regular basis?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
16. Are you taking any herbal supplements of any kind?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
17. Do you have diabetes?
RESPONSE: [I have Type 1 Diabetes / I have Type 2 Diabetes / No]
18. Do you have or have you ever had any of the following?
[List of selected conditions from: Arthritis/Rheumatism, Asthma, Cancer, Chest Pain/Angina, Crohn's Disease, Drug/Alcohol Dependency, Fainting or Dizzy Spells, Glaucoma, Hay Fever, Head/Neck Injuries, Heart Attack, Hepatitis A, Hepatitis B, Hepatitis C, Herpes - Oral/HSV-1, Hyperglycemia, Hypoglycemia, Jaundice, Kidney Disease, Liver Disease, Lung Disease/Emphysema, Malignant Hyperthermia, Mitral Valve Prolapse, Pacemaker, Psychiatric/Mental Disorders, Rheumatic/Scarlet Fever, Seizures (Epilepsy), Shortness of Breath, Sickle Cell Disease, Sinus Trouble, Stomach Ulcers, Hay Stroke, Thyroid Disease, Tuberculosis]
SELECTED CONDITIONS:
  • • [Selected Condition 1]
  • • [Selected Condition 2]
  • • [Selected Condition 3]
  • [Patient's Selected Conditions List]
19. Do you have or have you had any conditions or diseases not previously listed that we should be aware of?
RESPONSE: [Yes / No] | IF YES, PLEASE LIST: [Details]
20. Are there any diseases or medical problems that run in your family?
RESPONSE: [Cancer, Heart Disease, Diabetes, Malignant Hyperthermia, Other] | [Other Details]
21. Do you have a bleeding problem or bleeding disorder?
RESPONSE: [Yes / No]
22. Do you have or have you ever had a replacement or repair of a heart valve or stent?
RESPONSE: [Yes / No]
23. Do you have or have you ever had an infection of the heart? (e.g. Infective Endocarditis)
RESPONSE: [Yes / No]
24. Have you had a transplant (heart, lungs, organs)?
RESPONSE: [Yes / No]
25. Do you have a heart condition from birth? (e.g. congenital heart disease/lesions)
RESPONSE: [Yes / No]
26. Do you have or have you ever had any heart or blood pressure problems?
RESPONSE: [Yes / No]
27. Do you have a prosthetic or artificial joint?
RESPONSE: [Yes / No]
28. Have you ever been hospitalized for any illnesses or operations?
RESPONSE: [Yes / No]
29. Have you ever had any injury or surgery to your face or jaws?
RESPONSE: [Yes / No]
30. Do you smoke or chew tobacco products?
RESPONSE: [Yes / No]
31. Are you nervous during dental treatment?
RESPONSE: [Yes / No]
32. Is there anything else about your health that we should be made aware of?
RESPONSE: [Yes / No] | IF YES, PLEASE PROVIDE VERY BRIEF DETAILS: [Details]
33. Do you wish to speak to the doctor privately about any problem or medical condition?
RESPONSE: [Yes / No]
34. Has the child patient recently had any of the following?
RESPONSE: [Chicken Pox, Measles, Mumps, Chest Strep Throat, Tonsillitis, None/None Applicable]
35. Are there any immunizations that the child is not up to date with?
RESPONSE: [Yes / No]
36. Are you breastfeeding?
RESPONSE: [Yes / No]
37. Are you pregnant?
RESPONSE: [Yes / No/Not applicable]
TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATION CHANGES, I WILL INFORM THE DOCTOR AT THE NEXT APPOINTMENT WITHOUT FAIL.
DIGITALLY ENDORSED BY PATIENT
[Patient Signature Placeholder]
DATE SUBMITTED
[MM/DD/YYYY]
David Gouett Dentistry

© 2026 David Gouett Dentistry. This record is protected under PIPEDA and PHIPA legislation. Unauthorized disclosure of this clinical information is strictly prohibited.