Patient Name

D.O.B

Address

City

Postal Code

Phone

Emergency Contact Name

Emergency Contact Number

Referred by

Employer/School

Can We Contact You Via Email?

Yes No

Insurance Holder Name

D.O.B

How did you hear about us?

Please tell us about others

Last Visit

Dentist Name

Rate Oral Health

Good Fair Poor

Last X-rays

Are You Being Treated For Any Medical Conditions Presently Or Within The Last Two Years?

Date Of Your Last Medical Check up:

Family Physician:

Have there been any changes in your general health within the past year?

Yes No

If yes, please explain

Have you ever had a peculiar or adverse reaction to any medicines or injection?

Yes No

If yes, please explain

Do you have or have you ever had asthma?

Yes No

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

Yes No

Have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e., infective endocarditis), a heart condition from birth (i.e., congenital heart disease) or heart transplant?

Yes No

Do you have a prosthetic or artificial joint?

Yes No

Do you have any condition or therapies that could affect your immune system (i.e., leukemia, AIDS, HIV infection, Radiotherapy, Chemotherapy)?

Yes No

Have you ever had hepatitis, jaundice or liver disease?

Yes No

Do you have a bleeding problem or bleeding disorder?

Yes No

Have you ever been hospitalized for any illness or operations?

Yes No

If yes, please explain

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

Yes No

If yes, please explain

Are there any diseases or medical problems that run in your family? (i.e., diabetes, cancer, or heart disease)

Do you smoke or chew tobacco products?

Yes No

Are you nervous about dental treatment?

Yes No

Note: The following fields are for female patients only.

Are you breastfeeding or pregnant?

Breastfeeding Pregnant

What is the expected delivery date?

Are there any conditions or diseases not listed above that you have or have had? Please explain.

Welcome: We would like to welcome you to our office, Skyway Dental Care. Our philosophy revolves around comfort and satisfaction. We intently listen to your desire to create the unique smile that you want and deserve. We feel passionate about each and every smile that we create. Our highly trained team will ensure your experience is above and beyond your expectation.

Confidentiality: Please note that all the information collected is private and confidential. We do not release any information without your consent.

Appointment Cancellation Policy:

1st missed appointment: If an appointment is missed or cancelled without sufficient notice, a letter will be sent to your home reminding you of our policies and the effects of your missed appointment.
2nd missed appointment: In the event a second appointment is missed or cancelled with less than 48 hours notice, or no notice, a $50 charge will be billed and a letter will be sent to your home advising of incurred charge.

Appointment Cancellation Policy

I have read and understood the Appointment Cancellation Policy.

Patient Name

Signature

Date

Dentist Name

Signature

Date

New Patients

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