Patient Intake Form

Rosedale Dental Care
55 Kennedy Road North, Brampton, ON L6V 1X6
Phone: 905-459-7645 | 905-459-4613
Email: smile@rosedaledentalcare.com

The information in this questionnaire is confidential and enables our office to provide the highest level of care and service possible. Please complete the below form. Thank you.

Patient Contact Information

First Name

Last Name

Patient's D.O.B. (DD/MM/YYYY)

Sex

Male Female

OHIP Number

Address

City

Province

Postal Code

Home Number

Work Number

Cell Number

E-mail Address

Best way to contact you?

Home Work Cell E-mail

Person to contact in case of an emergency (relationship)

Phone Number

Family Doctor

Phone Number

Insurance Information

Do you have dental insurance?

Yes No

Primary Insurance Company Information

Name of Insurance Policy Holder

Date of Birth (DD/MM/YYYY)

Insurance Policy Holder

Self Parent/Guardian Other

Policy Holder Phone Number

Insurance Company Name

Group Policy/Plan Number

I.D./Certificate Number

Secondary Insurance Company Information

Name of Insurance Policy Holder

Date of Birth (DD/MM/YYYY)

Insurance Policy Holder

Self Parent/Guardian Other

Policy Holder Phone Number

Insurance Company Name

Group Policy/Plan Number

I.D./Certificate Number

Referral Information How did you hear about us? (Check at least one)

Medical History

Have you had a medical check-up in the last year?

Yes No

If yes, when?

Have you ever been hospitalized or had major operations?

Yes No

If so, please explain

Are you currently under a physician's care?

Yes No

If yes, what for?

Have you ever had an unusual reaction to any medications or injections?

Yes No

If yes, please describe

Are you taking any medications, non-prescription drugs, recreational drugs, or herbal supplements?

Yes No

If yes, please specify

Do you drink alcohol?

Yes No

Do you smoke, vape or chew tobacco products?

Yes No

Do you require pre-medication for dental treatment?

Yes No

If yes, please explain

Have you ever had any organ implant or medical implants? (i.e. valves, stents, joints)

Yes No

If yes, please specify

Do you experience shortness of breath or chest pains when taking a walk or climbing stairs?

Yes No

If yes, please specify

Have you had any injury, surgery or x-ray therapy to your face or jaws?

Yes No

If yes, please specify

Do you have any allergies?

Yes No Maybe

a) Medication

b) Latex / rubber products / metals

c) Other

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

	Yes	No		Yes	No
Anemia			High Blood Pressure
Diabetes			Thyroid Disease
Asthma			Bronchitis / Emphysema
Lung Disease			Angina
Arrhythmia			Angioplasty / Stents
Heart Attack			Pacemaker
Jaundice			Hepatitis
Bulimia			Kidney Disease
Osteoporosis Medication			Glaucoma
Steroid Treatment			Drug / Alcohol Dependency
Heart Surgery			Congenital Heart Defect
Rheumatic Fever			AIDS
HIV			Blood Disorders
Arthritis / Rheumatism			Artificial Joint
Anorexia Nervosa			Stroke
Migraine / Headaches			Mental Health Disorders
Multiple Sclerosis			Epilepsy / Seizures
Head / Neck Injuries			Tuberculosis
Cancer			Leukemia
Radiation			Chemotherapy
Organ Transplant			Sinus Trouble
Sleep Apnea			Gastrointestinal Issues
Venereal Disease
If Any Other Illness (please specify):

For Women Only

Are you pregnant or suspect you might be?

Yes No

If so, what month are you in?

Are you taking birth control pills?

Yes No

Are you nursing?

Yes No

Dental History

1. Last dental visit?

2. What was done on the last visit

3. How frequently do you see your dentist?

5. How would you describe your dental health at present?

Good Fair Poor

6. Are you satisfied with the appearance of your teeth?

Yes No

Are any of your teeth sensitive to heat, cold, sweets or pressure?

Yes No

7. Do your gums bleed when brushing, flossing or eating?

Yes No

8. Are you anxious during dental visits?

Yes No

Privacy & Release Information

Release of Information: I authorize Rosedale Dental Care to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history from my physician, another dental office, or insurance company.

Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment, we require 2 days notice.

Patient Release: I understand that providing incorrect information can be dangerous to my health. I agree that it is my responsibility to inform the office of changes in health or medical status.

I agree to the above terms.

Signature

Patient / Guardian Name (typed)

Date

Dentist

Date

Patient Intake Form

Do you have dental insurance?

Primary Insurance Company Information

Secondary Insurance Company Information

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

Book an appointment

Directions

Services

Services

Business Hours