New Patient Form

New Patient Form - Medical History

Patient First Name:

Patient Last Name:

Dentist: Please Select Dr. Andrew Doig Dr. Ryan Gallagher

1. Are you in Good Health

Yes No

2. Have you had an unusual reaction to drugs/medications? To what? i.e. Penicillin

Yes No

3. Is your physician treating you now?

Yes No

Reason?

4. Are you taking any medication? (prescription or over the counter)

Yes No

Please list

Pharmacy contact info

5. Do you smoke or use tobacco products?

Yes No

6. Do you use recreational medical marijuana?

Yes No

7. Do you have any allergies?

Yes No

Please list

8. Do you experience shortness of breath?

Yes No

9. Have you gained or lost excessive weight recently?

Yes No

10. Do you have heart disease or murmur? Heart Attack?

Yes No
If so, when?

11. Are your ankles often swollen?

Yes No

12. Have you ever had radiation treatment?

Yes No

13. For women only, are you any of the following?:

Pregnant

Nursing

HRT

14. Have you had any of the following? (check all that apply):

Heart trouble
High Blood Pressure
Rheumatic Fever
Blood disorders
Diabetes
Epilepsy
Thyroid trouble
Kidney trouble
Cancer
HIV/AIDS
Asthma
Tuberculosis
Pic Line
Anemia
STD
Hepatitis
Liver trouble

Other:

New Patient Form - General Inoformation

1. Birthday

2. Address

3. Postal Code

4. Home Phone

5. Work Phone

6. Cell Phone

7. Email

8. Health Card Number

9. Spouse/Parent Name

10. Employer/Occupation

11. Referred by:


This is to certifiy that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and i will assume responsibility for fees associated with those procedures. I acknowledge reviewing the College Park Dental privacy policy and understand my rights of privacy with respect to me (and any dependent children) personal information. I further consent to the collection, use and disclosure of my (or dependent child's) personal information;
(please check the boxes)

To provide dental services

To maintain communications with healthcare specialists and to provide me (us) with information and follow up respecting my dental care;

To communicate with my insurance plan(s) to facilitate the processing of my claims;

For the uses, purposes, and disclosures described in the privacy act.;

Dental Questionaire

1. Have you had any of the following?:

a. Orthodonic treatment (teeth straightened)

b. Surgery to teeth, jaws or face

c. Trauma to teeth, jaws or face

d. Periodontal (gum) treatment

2. Do you now or have you ever had sinus problems?

3. Have you ever had abnormal bleeding after an extraction or a cut?

4. Have you ever had a bad reaction to freezing or freezing that did not take?

5. Do you grind your teeth while awake or asleep?

6. Do you have any jaw joint problems: e.g. clicking, popping, pain?

7. Do you suffer from frequent headaches?

8. Are your teeth sensitive to hot or cold?

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

Submit