General Patient Information Last name First name MF Gender Date of birth Age Email Phone (cell) Phone (work) Phone (home) Address City Postal code Ramq/ohip Expiration YesNo Do you have dental insurance? Insurance Companies AcceptedAccertaAlberta Blue CrossAssociation des policières et policiers du QuébecAssumption LifeAutobenBenecaidBenefits TrustSecure IndemnitéCompagnie d’assurance du Canada sur la vie (Fusion entre Great West Life – London Life – La Canada vie)Co-operatorsCommission de la construction du QuébecCoughlin & AssociatesCowan Insurance GroupDesjardins InsuranceEmpire Life InsuranceEquitable LifeGreen Shield CanadaGroupe Financier AGAGroupe Premier MedicalGroup Health Benefit SolutionHumania Assurance IncIndustrial AllianceIndustrial Alliance Pacific Life InsuranceJohnson Inc.Johnston GroupLa CapitaleLee PowerManitoba Blue CrossManulife FinancialMedavie Blue CrossNational Life of CanadaNexgenRXPacific Blue CrossPBAS GroupRBC InsuranceSSQ Financial GroupSun Life FinancialOtherIf so, what is the name of your insurance compagny? The drop-down menu suggests insurance companies accepted by our system for e-quotes. If your insurance company is not on this list, we will not be able to electronically send the quote. Please bring your insurance information to your appointment so we may send the e-quote to your insurance company. It will be given to you at the clinic and it is your responsibility to send it. Certificate number Insurance Plan Insured person's first name Insured person's last name Insured person's date of birth Patient's relationship with the insured person Occupation Dentist Family Physician Orthodontist 12345678910 Rate your anxiety level regarding a dental surgery procedure: Reason for consultation How did you hear about us? Medical history Weight Height Do you have or have you ever had: (Check the boxes that apply to your past or present situation.) DiabetesThyroid problemsOsteoporosisInfarct/AnginaDigestive problemsCancerEndocarditis (heart infection)Gastrointestinal problems (ulcers or reflux)HIVValvulopathy (trouble with heart valves)Kidney diseaseSexually transmitted diseaseHeart murmur or cardiac malformationOther pulmonary problemsRadiotherapy treatmentThrombophlebitisLiver diseaseChemotherapy treatmentPulmonary embolismHepatitisHigh blood pressureCoagulation problemsArthritisLow blood pressureAsthma or COPDEpilepsyTuberculosis Other medical questions or habits Do you have any implants in your body (heart valve, knee, hip)? YesNo If so, which implant and since when? Do you suffer or have you suffered from sleep apnea symptoms? YesNo If so, have you ever done a polysomnography (PSG) (sleep study)? YesNo Do you drink alcohol? YesNo If so, how many beverages per week? Do you smoke? YesNo If so, how much per day? Do you use marijuana products? YesNo If so, how often? Do you use any street drugs? YesNo If so, which ones? Are you pregnant? YesNo If so, which trimester? Are you nursing? YesNo Any other health problems you want to mention? Allergies and medication Do you have any allergies to any medication? YesNo If so, which ones? Have you (or a familly member) ever had complications due to general anesthesia? YesNo If so, explain: Do you have any known food allergies? YesNo If so, which ones? Are you on (or have you ever been on) bisphosphonates (i.e. Fosamax, Actonel, Didrocal) or other medication such as Xgeva (Prolia)? YesNo Are you taking blood thinners? YesNo If so, which ones? Are you taking any herbal medicines? YesNo If so, which ones? Please list all medications that you are taking: If necessary, include a list: Add a file A 48-hour notice is required when you want to cancel or change an appointment. In the case of Non-compliance of this policy, a $105 fee will be charged to your account. I agree that pictures taken during my appointments can be used for teaching or publishing purposes. I agree to receive email concerning my care. Date Patient name Patient signature /Legal guardian
