New Patient Form Additional Adult Patient Information (Confidential). All fields are mandatory, please enter n/a if they do not apply. Name of Person on the original form* First Name Last Name Name of Patient* First Name Last Name Birth Date* MM slash DD slash YYYY Marital Status*MarriedSingleOtherSelect a Choice* Male Female Work PhoneCell PhoneEmail* Employer* Spouses Name* Person to Contact in Case of Emergency* University/College Student* Full Time Part Time N/A How would you prefer your appointment reminders?* Via Mail Phone Call Text Message Relationship to Patient* Phone Number*Do you have insurance?* YES NO Do you have secondary insurance?* YES NO Are you dissatisfied with the appearance of your smile?* YES NO Do you have? (please check the following that apply)* Chipped Teeth Protruding Teeth Crowded Teeth Misshapen Teeth Teeth with Spaces or have gaps Teeth with old fillings or dental work None If you could change one thing about your smile, what would it be?* What is your primary reason for booking the appointment is today?* Have you had a negative experience, or is there something you would like us to know that will help us make your visit more comfortable?* Patient Medical HistoryPhysician* Physician's Office Phone*Are you currently under any medical treatment?* YES NO Have you been admitted to a hospital or needed emergency care during the past two years?* YES NO Are you currently taking any medications, including over the counter medications?* YES NO Have you ever had any complications following dental treatment?* YES NO Are you pregnant?* YES NO Do you have any allergies to medications?* YES NO Do you have or have had any of the following? Please check all that apply.* AIDS/HIV Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizzieness Epilepsy Excessive Bleeding Fainting Glaucoma Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure Kidney Disease Liver Disease Mental Disorders Pacemaker Radiation Therapy Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Strock Tuberculosis Tumors Venereal Disease Smoker None Patient Dental HistoryCheck All That Apply* Gums bleed while you brush Your teeth are sensitive to hot or cold liquid/foods You feel pain in any of your teeth Have any sores/lumps in your mouth Have any head, neck or jaw injuries Ever experience any clicking or pain in the TMJ area, difficulty opening or closing Have frequent headaches You clench or grind your teeth You bite your lips or cheeks frequently Had any difficult extractions or prolonged bleeding from it in the past Had any orthodontic treatments You wear dentures or partials None Upload a PhotoWe need a photo of of each patient for our records. If you have a clean headshot of the patient above please upload it here. Otherwise we can take a photo when they arrive.Max. file size: 50 MB.I agree to pay value of said services,which shall be as billed unless objected to by me, in writing, within the time for payment thereof. I agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I understand my personal information disclosed is protected by the Privacy Act. I agree that South Airdrie Smiles can electronically file dental claims on my behalf. In compliance with Canadian Anti-Spam Laws, you understand that by clicking submit, you give us permission to send you information on products and services and information such as news and events.** I have read the above conditions of treatment and payment and agree to their content.