Become a
New Patient

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Emergency Contact Number *

(###)

###

####

Where did you here about us *

Online search

Family / Friend

Social media

Newspapers / Magazines

Other

Phone *

(###)

###

####

1. Are you being treated for any medical condition at present or have you been treated within the past year? *

YES

No

2. When was your last medical checkup? *

MM

DD

YYYY

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

YES

NO

4. Are you taking any medications, non-prescription or herbal supplements of any kind? *

YES

NO

5. Do you have any allergies? *

YES

NO

6. Have you ever had a peculiar or adverse reaction to any medicines or injections? *

YES

NO

7. Do you have or have you ever had asthma? *

YES

NO

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

YES

NO

9. Do you have or have you ever had a heart murmur, mitral valve prolapsed or rheumatic fever? *

YES

NO

10. Do you have artificial or prosthetic joints? *

YES

NO

11. Have you ever been advised by your doctor to take antibiotics before dental treatment? *

YES

NO

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

YES

NO

13. Have you ever had hepatitis, jaundice or liver disease? *

YES

NO

14. Do you have a bleeding problem or bleeding disorder? *

YES

NO

17. Are there any conditions or diseases not listed above that you have or have had? *

YES

NO

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

Chest Pain/Angina

Shortness of Breath

Pacemaker Steroid Therapy

Seizures (Epilepsy)

Drug/Alcohol Dependency

Heart Attack

Lung Disease

Diabetes

Kidney Disease

Stroke

Prosthetic Heart Valve

Tuberculosis

Stomach Ulcers

Thyroid disease

Cancer

Arthritis

Hepatitis

18. Are there any diseases or medical problems that run in your family? (Cancer, diabetes, or heart disease) *

NO

YES

19. Do you smoke or chew tobacco products? *

YES

NO

20. Are you nervous during dental treatment? *

YES

NO

21. For women only: Are you breast-feeding or pregnant?

YES

NO

Name *

First Name

Last Name

Patient

Parent

Guardian

Date

MM

DD

YYYY

I have read and understand this document in its entirety; outlining the office and financial policies of Argyll Dental and agree to these terms: *

I Agree

Name of patient or parent/guardian:

First Name

Last Name

Date

MM

DD

YYYY