New Patient / 5-Year Update Form

Kitchener Dentist Centre - Sorin Boeriu DDS

866 Frederick Street
Kitchener, ON N2B 2B8 Canada
Phone: (519) 578-7830

Patient Information

Today's Date *

Patient Name *

Date of Birth *

Age *

Family Status *

Gender

What sex were you assigned at birth?

Male Female

What is your current gender identity?

Male Female Other

Specify Current Gender

Preferred Gender Pronoun A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you.

What pronouns do you prefer that we use when referring to you? (Check all that apply.)

She / her / hers He / him / his They / them / theirs Other

Specify Pronoun

Contact Information

Address *

Home Phone

Cell Phone

Email *

Work Phone

Extension Number

Health Card Number

Family Physician *

Physician's Phone *

In Case of Emergency, We Should Notify *

Relationship *

Phone *

Employer Name

Occupation

Payment Information

Party responsible for payment *

Self Other

Party Responsible for Payment

Relationship

Insurance Information

Please note: the patient is responsible for providing us with a copy of their insurance card(s).

Primary Insurance

Insurance Provider

Group Number

Certificate Number

Name of Insured

Is Insured a Patient?

Yes No

Patient's Relationship to Insured

Insured's Birth Date

Age

Secondary Insurance

Insurance Provider

Group Number

Certificate Number

Name of Insured

Is Insured a Patient?

Yes No

Patient's Relationship to Insured

Insured's Birth Date

Age

Medical History

Do you or have you ever had an adverse reaction or allergy to:

Antibiotic

Please specify:

Aspirin / Advil Codeine Latex Local Anesthetics / Novocain Other

Please Specify

Do you take blood thinners, such as Coumadin or Plavix? *

Yes No

Specify the date and score of your most recent INR

Do you take any other medications, vitamins, or supplements? *

Yes No

List any medications and dosage, including herbal products *

Have you ever had any of the following? Please check those that apply:

Neural

Seizures / Epilepsy Dizziness Nervous / Mental Disorders Stroke Depression

Cardiovascular

Angina Heart Attack Bleeding Disorder High / Low Blood Pressure Heart Disease Pacemaker Rheumatic Fever Heart Murmur

Pulmonary

Asthma / COPD Difficulty Breathing Respiratory Problems Tuberculosis

Where do you keep your inhaler?

Infectious

AIDS / HIV Hepatitis A / B / C Venereal Disease

Immune

Hay Fever Allergy

Neoplastic

Cancer Growths / Tumors Radiation / Chemotherapy

Digestive

Acid Reflux Disease Stomach Problems Ulcers

Inflammatory

Arthritis Rheumatism Osteoporosis

Other

Diabetes Artificial Joints Glaucoma Sinus Problems Liver Disease Kidney Disease Sleep Apnea Organ Transplant Thyroid Problems

Specify any of the above conditions

Surgery Details If you had any surgeries, please specify the surgery date and information.

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

Yes No

What are they?

Have you ever had any complications following dental treatment? *

Yes No

Please explain

Have you or anyone related to you ever had problems with local anesthetic? *

Yes No

Please explain

Are you pregnant or is it possible you are pregnant? *

Yes No

Due Date

Are you now under the care of a physician regarding an ongoing medical issue? *

Yes No

Please explain

Do you have any health problems that need further clarification? *

Yes No

Please explain

Do you smoke? *

Yes No Used to

How many cigarettes a day?

When did you quit?

Do you use any recreational drugs? *

Yes No

Please list which kind

Do you have a prosthetic or artificial joint? *

Yes No

Where?

Do you have or have you ever had replacement or repair of a heart valve, infection of the heart, a congenital heart condition, or a heart transplant? *

Yes No

Dental History

When was your last dental visit? *

When did you last have dental X-rays? *

How often do you floss your teeth? *

How often do you brush your teeth? *

Have you been seeing a dentist regularly? *

Yes No

Do any of your teeth ache? *

Yes No

Do your gums bleed when you brush? *

Yes No

Do you have pain when you chew? *

Yes No

Do you feel you have bad breath? *

Yes No

Please list anything else not mentioned above regarding your past dental history.

Referral Information

Whom may we thank for referring you to our practice? *

If referred by a current patient, provide their name so we can thank them.

Please Specify

Consent for Services & Office Agreement

Signature of patient, parent, or guardian *

Date *

New Patient / 5-Year Update Form

Kitchener Dentist Centre - Sorin Boeriu DDS

Primary Insurance

Secondary Insurance

Neural

Cardiovascular

Pulmonary

Infectious

Immune

Neoplastic

Digestive

Inflammatory

Other

About Us

Dental Procedures

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