New Patient Intake Form New Patient Intake PATIENT INFORMATION Contact InformationFirst Name(Required)Middle NameLast Name(Required)Preferred NameBirth Date(Required) YYYY dash MM dash DD Phone - HomePhone - WorkCell PhoneEmail I authorize Cypress Dental to contact me via email and SMS.(Required) Yes No Preferred method of contact: Home Cell Work Email Unit / BuildingStreet AddressCityPostal CodeYour Physician's AddressPhone NumberEmergency ContactRelationship to PatientPhone NumberInsurance Information- Primary InsurancePlan Holders First & Last nameDate of Birth YYYY dash MM dash DD Relationship to patientPhoneInsurance companyEmployerGroup/Policy/Contract/Plan#Certificate/ Member ID#- Secondary InsurancePlan Holders First & Last nameDate of Birth YYYY dash MM dash DD Relationship to patientPhoneInsurance companyEmployerGroup/Policy#Certificate /Div /ID#REFERRAL INFORMATION Name:Choose:FriendRelativeDoctorSpecialistPlatform:GoogleOther search engineFacebookInstagramOther:COMMUNICATIONS I authorize Cypress Dental to contact me via email and SMS: Yes No Preferred method of contact: Home Cell Work Many dental insurance plans allow us to submit claims electronically on your behalf. In order to do this, we require your authorization. I authorize the release of information contained in claims submitted electronically to my dental benefits provider. I authorize the communication of information related to dental coverage and benefits to my dental insurance provider. If allowed, I also assign my benefits payable from claims submitted electronically and authorize payment directly to this dental practice.Agreement checkbox(Required) I agree and understand completely the statement above, and I am authorizing the dental practice to send claims and communicate to my insurance company on my behalf. Date: YYYY dash MM dash DD Signature of patient or parent/guardian of minor:(Required)MEDICAL HISTORY 1. What is your estimate of your general health?(Required) Excellent Good Fair Poor 2. Are you presently receiving any treatment for any illness (i.e osteoporosis, cancer, upcoming surgeries, developmental delays)?(Required) Yes No Treatment detail: If no, please provide details:3. Do you currently smoke?(Required) Yes No Have you ever been a smoker?(Required) Yes No Do you currently smoke? If yes, please provide details (i.e., tobacco, marijuana)(Required)Have you ever been a smoker? If yes, please provide details (i.e., tobacco, marijuana)(Required)4. Have you had any of the following: prosthetic heart valve replacement, heart transplant, congenital heart disease, infective endocarditis?(Required) Yes No If yes, has your doctor instructed you to take pre-medications before dental treatment?(Required) Yes No Not Sure 5. Are you taking any medication or non-prescription drugs?(Required) Yes No Do you have allergies? details6. Have you ever had a peculiar or adverse reaction to any medication or injections? (e.g. penicillin, aspirin, local anesthesia or dental freezing)(Required) Yes No If yes, please describe symptoms/reaction7. Do you have allergies?(Required) Yes No If yes, please provide detailsPlease check the box if you presently have or ever had any of the following:Acid Reflux Acid Reflux Any lumps or swelling Any lumps or swelling AIDS/HIV AIDS/HIV Alcohol or substance dependency Alcohol or substance dependency Anemia Anemia Arthritis or Rheumatism Arthritis or Rheumatism Artificial joints / valves Artificial joints / valves Asthma Asthma Blood transfusion Blood transfusion Cancer Cancer Chemotherapy Chemotherapy Diabetes Diabetes Eating disorders Eating disorders Epilepsy / seizures Epilepsy / seizures Fainting/dizzy spells Fainting/dizzy spells Frequent headaches or earaches Frequent headaches or earaches Heart attack Heart attack Head or neck injuries Head or neck injuries Hepatitis (*) Hepatitis (*) High blood pressure High blood pressure Low blood pressure Low blood pressure Hyperglycemia Hyperglycemia Jaundice Jaundice Hypoglycemia Hypoglycemia Kidney disease Kidney disease Liver disease Liver disease Lung disease/chest pains Lung disease/chest pains Mental or nervous disorder Mental or nervous disorder Pacemaker or implantable defibrillator Pacemaker or implantable defibrillator Prosthetic joint Prosthetic joint Radiation therapy Radiation therapy Stomach ulcers Stomach ulcers Stroke Stroke Thyroid problems Thyroid problems Tuberculosis Tuberculosis Tumor / abnormal growth Tumor / abnormal growth Viral infection/cold sores Viral infection/cold sores ARE YOU FEMALE: taking birth control ARE YOU FEMALE: taking birth control ARE YOU FEMALE: pregnant If yes, due date? ARE YOU FEMALE: pregnant If yes, due date? (**) ARE YOU MALE: prostate disorders ARE YOU MALE: prostate disorders Type of Hepatitis (*)(Required)Due date (**)(Required) YYYY dash MM dash DD 8. Is there any additional information related to your health that has not been addressed above (i.e. past or upcoming surgeries)?DENTAL HISTORY Last Dental Visit: less than 1 year 1-5 years over 5 years Reason for last dental visit?Previous DentistDid you have any x-rays taken at the last appointment?(Required)If yes, please contact your previous office for your most recent x-rays, including any Panoramic x-rays, and have them send them to info@cypressdental.ca Yes No How often do you visit the dentist?(Required) twice a year once a year emergencies only How often do you brush your teeth in a day?(Required) none once twice three or more times How often do you floss your teeth in a day?(Required) none once twice three or more times Please check the box if you presently have or ever had anyof the following:Fear of dental treatment Fear of dental treatment An unfavorable dental experience An unfavorable dental experience Complications from past dental treatment Complications from past dental treatment Disappointment with appearance of previous dental work Disappointment with appearance of previous dental work Difficulty getting numb Difficulty getting numb Bleeding gums Bleeding gums Sensitive teeth Sensitive teeth if yes, to: Hot Cold Bite Sweets Sores, swelling or lumps in your mouth Sores, swelling or lumps in your mouth Head, neck, or jaw injuries Head, neck, or jaw injuries Have you ever had:Orthodontic treatment Orthodontic treatment Extractions Extractions Prolonged bleeding AFTER extraction Prolonged bleeding AFTER extraction Periodontal (gum) treatment Periodontal (gum) treatment Oral hygiene instructions Oral hygiene instructions A bite plate or mouth guard A bite plate or mouth guard Dentures or partial denture Dentures or partial denture Implants Implants Treatment from a specialist Treatment from a specialist if yes what type of treatmentOther issues:Loosening of teeth Loosening of teeth Food getting caught between your teeth Food getting caught between your teeth Dry mouth or excessive thirst Dry mouth or excessive thirst Burning or itchy sensation in your mouth Burning or itchy sensation in your mouth Unpleasant odor Unpleasant odor Bite your lips or cheeks regularly Bite your lips or cheeks regularly Snoring or sleeping disorders Snoring or sleeping disorders Do you experience any of the following problems in your jaw:Clicking Clicking Pain (ear, joint, or side of face) Pain (ear, joint, or side of face) Difficulty in opening / closing Difficulty in opening / closing Difficulty in chewing Difficulty in chewing Clenching or grinding Clenching or grinding I would like to improve:My smile My smile The way my teeth look The way my teeth look Dark fillings / tooth Dark fillings / tooth Thinning / shortened teeth Thinning / shortened teeth Additional comments or concerns?To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health, I will inform the dentist at the next appointment.Patient/Guardian signature(Required)Date(Required) YYYY dash MM dash DD WE WOULD LOVE TO GET TO KNOW YOU! These questions are optional but we appreciate you sharing.Why did you leave your last dentist:What kept you from completing your needed dentistry in the past? Time Cost Fear to injection Fear to noise Fear to pain other if other, please describeNo perceived problem No perceived problem Is there anything you would like us to know?OUR MISSIONOur office is committed to providing our patients with a dental experience that will promote a lifelong relationship built on trust, confidence, quality dentistry, and excellent patient care. Here at Cypress Dental we want to help change the way you feel about going to the dentist. Our specialized equipment, facility and staff are able to address all your dental needs in a relaxed and friendly manner. OUR OFFICE POLICIES Fees: Our fees are based on the quality of material we use and our clinical expertise and experience in performing your needed treatment. At the completion of an appointment payment is expected unless financial arrangements have been made in advance. Our payment options include cash, debit card, e-transfer, Visa, and MasterCard. Cancellation Policy: Cypress Dental requires a minimum of two business days notice if an appointment is to be cancelled or rescheduled. If less than two business days is given, a fee starting from $50 and up will be applied. Fee may be waived based on the situation and appointment length. Please be aware that insurance companies do not cover missed appointment fees. Insurance: Our office understands the value of insurance benefits to our patients. We will complete and submit your insurance claims and supply all documentation to maximize your benefits. Many dental insurance plans allow us to submit claims electronically on your behalf. In order to do this, we require your authorization to speak with your insurance company and release any information pertaining to your claim. release of information contained in claims submitted electronically to my dental benefits provider. I authorize the communication of information related to dental coverage and benefits to my dental insurance provider. If allowed, I also assign my benefits payable from claims submitted electronically and authorize payment directly to this dental practice. Patient/Guardian signature:(Required)Date:(Required) YYYY dash MM dash DD NameThis field is for validation purposes and should be left unchanged.
