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David Gouett Dentistry

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:

2 FINANCIAL & CREDIT INFORMATION

Person responsible for account:

Primary Dental Insurance

Secondary Dental Insurance

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?

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

4. Do you have any conditions that could affect your immune system? (e.g. Leukemia, HIV +/- tested, Lupus)

5. Are you undergoing any therapies that could affect your immune system? (e.g. Radiotherapy or Chemotherapy)

6. Are you currently taking any steroids or cortisone?

7. Do your ankles, feet or hands swell?

8. Are you allergic to any medications?

9. Are you allergic to any of the following?

10. Are you allergic to any foods?

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

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

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

14. Are you currently taking any prescription medications?

15. Do you take any recreational drugs on a regular basis?

16. Are you taking any herbal supplements of any kind?

17. Do you have diabetes?

18. Do you have or have you ever had any of the following?

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

20. Are there any diseases or medical problems that run in your family?

21. Do you have a bleeding problem or bleeding disorder?

22. Do you have or have you ever had a replacement or repair of a heart valve or stent?

23. Do you have or have you ever had an infection of the heart? (e.g. Infective Endocarditis)

24. Have you had a transplant (heart, lungs, organs)?

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

26. Do you have or have you ever had any heart or blood pressure problems?

27. Do you have a prosthetic or artificial joint?

28. Have you ever been hospitalized for any illnesses or operations?

29. Have you ever had any injury or surgery to your face or jaws?

30. Do you smoke or chew tobacco products?

31. Have you had bad experience?

32. Is there anything else about your health that we should be made aware of?

33. Do you wish to speak to the doctor privately about any problem or medical condition?

WOMEN ONLY

34. Are you breastfeeding?
35. Are you pregnant?

Dental History

Are you experiencing any dental problems?
1. Have you been seeing a dentist regularly?
2. Are there any growths or sore spots in your mouth?
3. Have you noticed any loose teeth, or have any of your teeth shifted?
4. Does food get caught between your teeth?
5. Are any of your teeth sensitive to heat, cold, sweets or pressure?
6. Have you been advised to take antibiotics before a dental appointment?
7. Do you use dental floss, proxabrush, or stimudents?
8. How often do you brush your teeth?
- Do you feel that you have bad breath?
9. Have you ever had one of the following?
- Periodontal treatment? (treatment of the gums)
- Orthodontic treatment? (to straighten or realign teeth)
- A bite plate or any other appliance?
- Your bite adjusted or teeth ground?
- Oral surgery? (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints?)
10. JAW PROBLEMS - Do you have any of the following?
- Popping/clicking in your jaw joints?
- Pain in your jaw joints, around your ear, or side of your face?
- Difficulty in opening or closing?
- Pain when teeth are clenched?
- Pain/difficulty in chewing?
11. Do you have any of the following habits?
- Clenching or grinding your teeth while awake or asleep?
- Biting your cheeks or lips regularly?
- Breathing through your mouth while awake or asleep?
- Hold foreign objects with your teeth (pencils, nails, pipes, pins, fingernails)?
12. Are you happy with the appearance of your teeth?

FINANCIAL AGREEMENT

Payment must be made the day of surgery. Our office will electronically file dental claims on your behalf if you have dental insurance.

A Charge of 200.00 for less than 48 hours' notice of cancellation appointment.

1

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and that I have not knowingly omitted data. Ontario has a law that protects personal health information. Dr. David Gouett and Associates maintain a strict privacy policy (for more information please ask to see the Privacy Policy). I agree that Dr. David Gouett and Associates can collect, use and disclose personal information in accordance with the privacy legislation set forth by the Province of Ontario. I give Dr. David Gouett and Associates permission to sent my dental claims electronically and confirm appointments or send referrals via email.

2

I assume all responsibility for fees associated with my dental treatment. Please note: A potential fee may be charged for any missed or rescheduled appointments without 2 full business days notice.

3

I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to David Gouett Dentistry. This authorization shall continue in effect until the undersigned revokes the same.