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Dr. Jordan Pettigrew - New Patient Form

Registration Information
Title





The patient is an test *


Patient Name (Surname, Given) *
Prefer to be called
Home Address (No, Street, City, Province) *
Postal Code *
Home Phone *
Work Phone
Cell
Birth Date *
Sex *


Employer / School
Occupation
Email
Whom may we thank for referring you?
Family Physician *
Phone *
In Case of Emergency Notify *
Relation *
Phone *
Person responsible for this account *





Name (Surname, Given)
Relation
Address (No, Street, City, Prov, Postal Code)
Home Phone
Work Phone

Insurance Information
(If you have a dental plan please complete the following)
Subscriber (Primary)
Relation



Insurance Co
Policy/Plan #
Subscriber I.D./Certificate #
Subscriber (Secondary)
Relation



Insurance Co
Policy/Plan #
Subscriber I.D.

Medical History
Have you ever had a serious illness requiring hospitalization or extensive medical care? *

If yes, please specify
Are you presently under the care of a physician? *

If yes, please specify
Have you had a medical examination in the last year? *

If yes, please specify
Do you use any prescription or non-prescription drugs regularly? *

If yes, please specify
Do you have any allergic conditions: e.g. hay fever, skin rash, food allergies, metal, latex? *

If yes, please specify
Do any allergic reactions result in headaches, shortness of breath, chest constriction, nausea? *

If yes, please specify
Have you been hospitalized in the last 5 years? *

If yes, please specify
Have you ever experienced any unusual reaction to any of the following? *








Other
Have you been warned against taking any drug or medication? *

If yes, please specify
Do you bruise easily or bleed abnormally? *

If yes, please specify
Have you ever had any organ implants or medical implants? *

If yes, please specify
Have you ever fainted? *

If yes, please specify
Do your ankles, feet or hands swell? *

If yes, please specify
Do you experience shortness of breath or chest pain when taking a walk or climbing stairs? *

If yes, please specify
Do you have frequent headaches? *

If yes, please specify
Do you have any conditions or therapies that could affect your immune system: e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? *

If yes, please specify
Do you have or ever had any of the following? *


























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

If yes, please specify
Do you have any disease, condition, or problem that you think the doctor should know about? *

If yes, please specify
WOMEN ONLY: Are you pregnant or suspect you might be? If so, what month are you in?

If yes, please specify
WOMEN ONLY: Are you taking birth control pills?

If yes, please specify

Dental History
Is there a dental problem you would like to take care of as soon as possible? *

If yes, please specify
Have you been seeing a dentist regularly? *

If yes, please specify
Last dental visit:
Last cleaning:
Full mouth series of x-rays:
How often do you brush your teeth? *
How often do you floss? *
Do your gums bleed easily? *

If yes, please specify
Are your teeth sensitive to: *





Do you feel you have bad breath at times? *

If yes, please specify
Have you ever had a jaw joint surgery? *

If yes, please specify
Do you have pain in your jaw joints or suffer from migraine headaches? *

If yes, please specify
Does any part of your mouth hurt when clenched? *

If yes, please specify
Does your jaw crack or pop when opened widely? *

If yes, please specify
Do you grind or clench your teeth during the day or night? *

If yes, please specify
Do you smoke or use any other forms of tobacco? *

If yes, please specify
Have you ever experienced any growths or sore spots in your mouth? If so, where? *

If yes, please specify
Previous problems with dental treatment? *

If yes, please specify
Are you satisfied with the appearance of your teeth? *

If yes, please specify
Please list any other dental concerns or questions:
Spam Prevention This field is to prevent spammers, please leave empty.



Office policy: Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be necessary to charge for the time lost.

Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and received answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.

(Signature) PATIENT PARENT GUARDIAN

Date (M/D/Y):

REVIEWING DENTIST

Westboro, Ottawa Location
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