FREE TEETH WHITENING

 * with new patient exam and cleaning.

New Patient Registration Forms

The first visit to our office is designed to get you better acquainted with all we offer as well as introduce you to Dr. Ajit Sandhu and our caring staff. We encourage questions and do our best to always deliver quality care.

Please take a moment prior to your scheduled appointment to print our new patient form. We ask that you complete the form and bring them with you to your appointment so we may better assist you in a timely manner. Thank you for your confidence in our office, we look forward to assisting you with all your dental needs.

 

PATIENT REGISTRATION AND HEALTH HISTORY

 

Welcome to our office. In order to provide you with excellent oral health care, we require a thorough medical and dental history.  All information is kept strictly confidential.

 

I. PERSONAL INFORMATION:

FULL NAME: __________________________________________________________________

BIRTHDATE: ___________________ (mm-dd-yy) SOC.INS.#_______________________

ADDRESS:____________________________________________________________________

TEL (HOME):___________________  WORK: _______________ OTHER: _________________

 

Whom may we thank for referring you to our office?:_________________________________

 

2. INSURANCE INFORMATION:

INSURANCE CARRIER: ____________________EMPLOYER:__________________________

GROUP # ______________        ID# ____________________

NAME OF INSURED: _____________________   BIRTHDATE:__________ ____    (mm-dd-yy)

 

SECONDARY CARRIER: ____________________EMPLOYER:__________________________

GROUP # ______________        ID# ____________________

NAME OF INSURED: _____________________   BIRTHDATE:__________ ____    (mm-dd-yy)

 

3. MEDICAL HISTORY: (CONFIDENTIAL)

PHYSICIAN NAME: __________________________PHYSICIAN PHONE:_________________

 

1. Are you in good health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Do you smoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Have you ever had a serious illness, operation, or hospitalization? . . . . . . . . . . . . . . . . . . . . . . . 4. Are you now under the care of a physician for any ongoing treatment or therapy?. . . . . . . . . . . . 5. My last physical examination was on:………………………………………………………………...

6. Are you now taking any medicine, drugs, or pills? . . . . . . . . . . . . . . . . . if so, list . . . . . . . ……. ...........................................................................................................................................................

7. Do you have any allergies? …………… to what?..........................................................................

8. Do you have or have you had any of the following diseases or problems? . . . . . . . . . . . . . . . . .

Any Heart Disease, Artificial Heart Valve, High Blood Pressure, Asthma, Tuberculosis,

Any Lung Disease, Hives or Skin Rash, Any Kidney trouble, Hepatitis, Jaundice,

Any Liver Disease, Ulcers,

Any Arthritis, Rheumatic Fever, Cancer, AIDS, Drug Addiction, Hemophilia, Epilepsy

9. Do you, or has any member of your family had diabetes? . . . . ……………………………………

10. Do you have any blood disorders or do you bleed excessively? . . . . . . . . . . . . . . . . . . . . . . . . 11. Have you ever had injury, surgery, or X-ray therapy to face or jaws? . . . . . . . . . . . . . . . . . . . . 12. Do you have a tendency to faint? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13. Do you have frequent severe headaches? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14. Are you on a special diet?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. Do you have a prosthetic implant? (i.e. hip/knee/valve?) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16. WOMEN ONLY - Are you pregnant?........................(Which month:………………….)

17. Do you have any disease, condition, or problem not listed above that you think the Dentist should know about? If yes, please explain:. . . . . . …………………….…………………………… . . . . ………………………………………………………………………………………………………………..

 

Date ____________________ Patient's Signature_________________________________

 

 

4. DENTAL HISTORY:

A. What concerns you most about your dental health?__________________________________

B. Do you see a dentist on a routine basis? . . . . . . . . . . . . . . Date of last dental visit?..................

Date of last dental cleaning?..........................Date of last X-rays?......................................

C. Are you having pain at this time?. . . ……………………………………………………………… . . .

D. Have you noticed any loosening of your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E. Does food tend to become caught between your teeth?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F. Do you suffer from pain and/or swelling of your gums? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

G. Do your gums often bleed when you brush your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

H. Problems of the jaw…………………….           Have you experienced:

i - Clicking of the jaw? . . . . . . . . . . . . .ii - Pain (joint, ear, side of face)? .  . . ………… . . .

iii - Difficulty in opening or closing? . . . . . . . . . . . .iv - Difficulty in chewing? . . . . . . . . . . .

I. Habits. Do you:

i - Clench or grind your teeth while awake or asleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ii - Mouth breathe while awake or asleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J. Do you feel nervous about having dental treatment? . . . . . . . . . . . . . . . . . . . . . . . .

K. Have you ever had an upsetting experience in a dental office?. . . . . . . . . . . . . . . . . . . . . . . . . .

L. Is it important to keep your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

M. If you could, what features of your smile would you like to change?............................................

N. Is there anything else about having dental treatment that bothers you? . . . . . . . . . . . . . . . . . . .

 

 

5. CONSENT:

The undersigned hereby authorizes the Dentist to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Dentist to make a thorough diagnosis of the patient's dental needs  I also authorize the Dentist to perform any and all forms of treatment, medication and therapy, that may be indicated after discussion and consultation between the patient (or guardian of) and the dentist including alternative options or the consequences of no treatment.

 

 

Insurance companies now only allow for "functionally acceptable work", whereas, in the past their coverage was for "quality  work". It is our desire to provide our patients with the highest quality work within their financial capabilities and desires.

 

 

 

______________________________________                                          ___________________

PATIENT                                                                                                           DATE

(OR LEGAL GUARDIAN IF PATIENT IS UNDER THE AGE OF 18)

Contact Details

Call Us
519-571-7117
Office
240- 1201 Fischer Hallman Rd. Kitchener, ON
Say Hi
info@kitchenerdentaloffice.ca

OPENING HOURS

Monday
CLOSED
Tuesday
CLOSED
Wednesday
CLOSED
Thursday
CLOSED
Friday
CLOSED
Saturday
CLOSED
Sunday
CLOSED