Request a Dental Appointment Online - Meadows Gate Dental Clinic

1Patient Information

2Emergency/Physician Information

3Medical & Dental History

4Medical & Dental History

5Office Policies/Submission

Patient Information

Name

Name *

First Name` *

Last Name

Date of Birth *

Sex *

Female
Male
Other

Address

Address Line 1

City

State / Province / Region

Postal / Zip Code

Country

Mobile

Home Phone

Email *

Care Card Number

Preferred method of communication

Home Phone
Mobile
Email
Any

Do you have someone that is assigned to make your decisions?

Name *

Phone *

Referred by

Drive-by/signage
Newspaper
Family/Friend
Social Media
Online
Other

Other

Who may we thank for referring you?

Emergency Contacts

Name

First

Last

Relationship

Phone

Family Doctor Information

Physician's Name

Phone

Medical & Dental Questionnaire

Are you currently taking any medications or vitamins?

Medications

Medication

Purpose

What is your primary concern today?

When did this become a concern?

I routinely see my dentist every:

3 months
4 months
6 months
12 months
Not routinely

How would you describe your last dental experience?

What prevented you from returning to your previous dentist?

Have you ever had braces or orthodontic treatment?

Do you experience anxiety during dental appointments?

How often do you brush your teeth?

Do you use a hard or soft toothbrush?

Do you use other dental aids (floss, mouthwash, etc.)?

Are your teeth sensitive to hot, cold, sweets or biting?

Interested in Botox Cosmetics?

Yes
No
Not Sure / Maybe

Interested in a Cosmetic Smile Makeover?

Yes
No
Not Sure / Maybe

Popping or clicking in jaw joints?

Yes
No
Not Sure

Jaw pain, ear pain or face pain?

Yes
No
Not Sure

Difficulty opening or closing mouth?

Yes
No
Not Sure

Pain when teeth are clenched?

Yes
No
Not Sure

Pain or difficulty when chewing?

Yes
No
Not Sure

Do you clench or grind your teeth?

Yes
No
Not Sure

Any facial or jaw surgery/injury?

Yes
No
Not Sure

Do you bite your cheeks or lips?

Yes
No
Not Sure

Do you smoke or use tobacco?

Alcohol or drug use history?

Ever received treatment for alcohol or drugs?

Have you ever been hospitalized in the last 5 years?

Yes
No
Not Sure / Maybe

For what condition?

Any infections we should know? (copy)

Bleed excessively from cuts or bruises?

Do you wear contact lenses?

Are you pregnant?

Are you breastfeeding?

Are you taking birth control pills?

Have you ever had an allergic reaction to the following?

Aspirin
Advil
Tylenol
Codeine
Penicillin
Erythromycin
Tetracycline
Latex
Sulpha Drugs
Freezing / Local Anesthetic
Fluoride
Metals (Nickel, Gold, Silver)
Other

Other

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

Antidepressant Medication
Diabetes
Heart Disease / Attack
High / Low Blood Pressure
Kidney Disease
Liver Disease
Sleep Apnea
Stroke
Temporomandibular Joint Disease
Other

Other (copy)

to cheeks concern

Medical & Dental History

Do you have dental Insurance *

Dental Insurance

Subscriber Name *

First

Last

Date of Birth *

Insurance Company *

Relationship to Subscriber *

Group # *

Certificate # *

In order to prevent misunderstanding about dental insurance...

THIS IS YOUR RESPONSIBILITY, AS ARE ANY FEES FOR SERVICES NOT COVERED BY YOUR PLAN.

APPOINTMENTS:

Appointment times are reserved especially for you. If you are unable to keep an appointment, please allow two business days notice to avoid a late cancellation or missed appointment fee of $100.

PERMISSION TO TREAT:

This is to certify that I, the undersigned, consent to dental and oral surgery procedures as determined necessary or advisable, including the use of local anesthesia. NOTE: IT IS IMPORTANT THAT ANY CHANGES TO YOUR HEALTH STATUS BE REPORTED TO OUR OFFICE

APPOINTMENT CHANGES / CANCELLATIONS:

If you need to make changes to the appointment date/time, please call our office directly. There will be a $100 fee for any no show or last minute cancellations.

Please give our office at least 3 business days notice.

Signature

Patient Signature *

Clear Signature

Date *