Aria Registration/Medical History NEW PATIENT
PERSONAL DETAILS
Your personal details. Please review them and make any necessary adjustments.
Title
Mr.
Mrs.
Ms.
Mstr.
Miss
Dr.
First Name
Last Name
Preferred Name
Gender
Female
Male
Non-Binary/Other
Unspecified/Prefer Not To Answer
Date of Birth
Address
Address 2
Province/State
City
Postal /Zip Code
Home #
Work #
Ext.
Mobile #
Other #
Preferred Phone
Home
Work
Mobile
Other
Email
Contact Method
Email
Phone
Mail
Sms
Employer/School
Occupation
Are you available for short notice appointments? (Check if available)
How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Relation
Emergency Phone #
INSURANCE INFORMATION
Your coverage details. Please review them and make any necessary adjustments.
Primary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
Secondary Insurance
Subscriber Name
Relationship
Self
Spouse
Common Law
Child
Other
Insurance Company Name
Policy #
Subscriber Date of Birth
Subscriber ID #
Div./Group Number
Employer
Additional Notes
MEDICAL HISTORY
Are you currently being treated by your physician for any reason? If yes, please explain
Yes
No
Have you ever been hospitalized or had a serious illness? If yes, please specify:
Yes
No
Have you ever had general anesthetic?
Yes
No
Have you ever had a reaction to local DENTAL ANESTHETIC?
Yes
No
Do you bruise easily or bleed excessively when cut?
Yes
No
Do you smoke tobacco products?
Yes
No
Are you currently taking any pills, drugs or other medications? If yes, please list or provide list
Yes
No
PERSONAL HEALTH HISTORY( PLEASE CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING)
Heart Disease or Chest paiin
High Blood Pressure
Low Blood Pressure
Heart Murmur
Pacemaker or artificial heart valves
Rheumatic fever
Diabetes
Lung problems/shortness of breath
Asthma
Kidney or liver problems/hepatitis
Drug or alcohol dependancy
Thyroid problems
Stomach or intestinal pain, ulcers
Arthritis
Tuberculosis
Tumours, cancer, chemotherapy or radiation
Artificial joint replacement
Epilepsy or seizures
Blood disorders
Syphilis, gonorrhea, AIDS
Taken Osteoporosis medication ( Fosamax, Actenol)
Taken blood thinners
Taken anti-depressants
Taken cortisone or steroid medication
Do you currently have or have had any disease, condition, or problem not listed above ?If yes, please explain:
Yes
No
Is there anything else concerning your health the doctor should know? If yes, please explain
Yes
No
Do you take aspirin daily?
Yes
No
ARE YOU ALLERGIC TO ANY MEDICATIONS OR DRUGS? IF yes, please explain
Yes
No
Do you have any other allergies? If yes, to what?
Yes
No
WOMEN ONLY :
Are you pregnant or suspect you might be? If yes, when are you expecting?
Yes
No
Are you taking birth control pills?
Yes
No
PATIENT CONSENT AND PRIVACY CODE
I understand your office has a Privacy Code , and that I may ask to see it at any time. I agree that Aria Dental Centre may collect, use and disclose personal information about myself and my family as set out in the privacy policies. I am a patient of Aria Dental Centre and authorize the said office to obtain insurance information and submit dental claims either electronically or manually on behalf of myself and my family.
APPOINTMENT CANCELLATIONS
If your scheduled appointment time is not convenient, we ask that two business days' notice be given. When two business days' notice is NOT given for a cancellation or if you fail to attend your appointment, a $75 charge may be applied to your account.
I HAVE COMPLETED THE ABOVE IN A COMPREHENSIVE AND TRUTHFUL MANNER TO THE BEST OF MY KNOWLEDGE
Patient Signature
FOR OFFICE USE ONLY
Reviewed by
Dr. Hassan Mostafa
Dr. Laura Mirzai
Dr. William Xie
Dentist comments
