Step 1 of 7 14% Patient InformationPatient Name* First Last E-mail Address* Phone*Preferred method of contact* Phone Email Date of Birth Day Month Year Gender Male Female Non-binary Address* City* Province* Emergency Contact Name* Emergency Phone*Allergies* Welcome to Ascent Dental Care!We strive to make our patient’s experiences within our office as comfortable as we can. Please help us understand your needs as a new patient to our office by answering the following questions.How did you hear about our office?* When was your last dental visit?* Do you have a primary concern (eg. pain, bleeding gums, esthetics)?* Yes No Please explain* What would be important during your visit in order for you to say you had a good experience?* Insurance InformationName of Insured Person First Last Date of Birth Day Month Year Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Group / Policy # ID / Contract # Employer Name Relationship of insured to patient* Self Spouse Parent Other Secondary Insurance InformationDo you have secondary insurance?* Yes No Name of Insured Person First Last Date of Birth Day Month Year Address Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Group / Policy # ID / Contract # Employer Name Relationship of insured to patient* Self Spouse Parent Other Insurance AuthorizationI authorize release, to my dental insurance company / plan administrator the information contained in claims submitted electronically from Ascent Dental Care. I also authorize the communication of information related to the coverage of services between Ascent Dental Care and my dental insurer.* Overall Health InformationWould you consider yourself to be in good health?* Yes No Please explain* Within the last year have there been any changes to your general health?* Yes No If yes, please explain* What is your primary care physician's name?* What is your primary care physician's contact information?* Please indicate if you have been diagnosed with or experience any of the following Alzheimer’s Disease Anemia Anxiety Arthritis Artificial Joints Asthma Autoimmune disease Blindness Cancer Chronic Lymphocytic Leukemia COPD Diabetes Dialysis Epilepsy Excessive Bleeding Fainting Gastro-intestinal issues Glaucoma Heart Disease Heart Attack Heart Murmur Heart Valve Replacement Hepatitis HIV+ Hypertension Hyperthyroidism Hypothyroidism Immune Deficiency Joint replacement Kidney Disease Knee Replacement Leukemia Liver Disease Low Blood Pressure Mental health issues Multiple sclerosis Nerve dysfunction / damage Pacemaker Parkinson’s Disease Pre-medication Respiratory Distress Rheumatic Fever Rheumatism Sinus inlammation Spinal stenosis Stroke Thyroid Disease TMJ issues Tuberculosis Tumors Ulcers Women only: Pregnant Due Date* For any checks above, please indicate date of diagnosis, area of body involved, and severityPlease indicate any known allergies Amoxicillin Aspirin Barbiturates Ciprofloxacin Clindamycin Codeine Erthromycin Ibuprofen Latex Local anesthesia Metal Morphine Nuts Penicillin Sulfa drugs Tetracycline Tylenol #3 Local anesthesia – specify Metal – specify Do you have any other health concerns or allergies? If so, please indicate below Please indicate the name of any medications you are currently takingIf you do not know the names of all of your medications, we can request the list from your pharmacy. Please provide the name and phone number of your pharmacy Dental Health InformationWhat is the reason for your dental visit today?* Is there anything you would like to change about your mouth, teeth, or smile? Yes No Please elaborate* When was your last visit to the dentist? What was done at your last dental visit? Are you nervous / anxious about having dental work done?* Yes No Please elaborate* How frequently do you brush your teeth?* At least 2x/day Once a day A few times a week Seldom How frequently do you floss your teeth?* Daily A few times a week Seldom Never Please check any of the following that apply to you Do your gums bleed when you brush or floss? Are your teeth sensitive to hot or cold? Are any of your teeth currently causing you pain? Do you grind your teeth (either consciously or during your sleep)? Is your goal to keep your teeth for as long as possible? Do you have any dental implants, dentures, or partial dentures? If you checked any of the above, please elaborate*Please indicate if there is anything else you would like us to know before your appointment Ascent Dental Care Privacy Policy* I acknowledge that I have read and understand the privacy policy Consent for Dental Services* I acknowledge that I have read and understand the consent for dental services policy EmailThis field is for validation purposes and should be left unchanged.
