Baywellesley Dental

FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Note: information marked with star (*) are mandatory and must be filled out.

Title

Mrs

other

I consent to receive appointment notifications and newsletters

Which one of below methods is the quickest and most reliable way to get in touch with you

HOME PHONE

WORK PHONE

CELL PHONE

TEXT MESSAGE

E‐MAIL

other

Notes (specific time of the day or any consideration):

Emergency Contact

Full Name *

Relationship

Emergency Cell Phone *

Emergency Home Phone

Notes (specific contact instructions or preferences)

Family Physician

Full Name

Office Phone

Specialist For:

Full Name

Office Phone

How can we help you?

Comprehensive Exam

Dental Hygiene/Cleaning

Pain Relief/ Emergency

other

How did you hear about us ?

Referral :

Name of Referee :

Please mark all that apply:

Facebook

Instagram

Google

Website

Signage

Flyers

other

Primary Insurance

Insured Name

First Name

Last Name

Date of Birth

Insured Employer

Insurance Company

Plan or Group

Certificate/Member ID

Secondary Insurance (if available):

First Name

Last Name

Date of Birth

Insured Employer

Insurance Company

Plan or Group

Certificate/Member ID

Relationship to Insured

Insured Cell Phone

When was your last Dental visit? *

When was your last Medical check‐up? *

Do you have tendency to bruise easily or bleed for a prolonged period of time? *

yes

Have you ever had or are receiving Chemo or Radiation Therapy? *

yes

Any ill effects from it?

Do you require any Medications or Antibiotics before Dental Treatment? *

yes

if yes, please provide details

Do you take cannabis/cannabis products? *

yes

Are you currently being treated for any Medical conditions? Are you currently being required to self‐isolate? *

yes

if yes, please provide details

Are you taking any Medications (including blood thinners such as Aspirin, Coumadin/Warfarin, Heparin, Eliquis, etc.) or Non‐Prescription Drugs? *

yes

if yes, please list all:

Has your physician ever told you to take antibiotics prior to dental procedures? *

yes

Have you ever taken or been given bisphosphonate medication or any of its family? *

yes

Have you ever taken cortisone or steroids? *

yes

Has there been any changes in your general health recently? Have you gained or lost excessive weight? *

yes

If yes, please provide details

Have you ever been seriously ill, hospitalized or had any major surgery? *

yes

If yes, please provide details

Have you ever had a peculiar or adverse reaction to any Medication, Injection or Anesthesia? *

yes

If yes, please provide details

Do you have allergies or sensitivities to any Food or Material (including Latex)? *

yes

If yes, please provide details

Have you ever had freezing (local anesthetic) in your mouth? *

yes

If yes, please provide details

Have you ever had a complete dental examination with a full series of dental x-rays within the past 3 years? *

yes

Have you ever had a bad experience at the dentist? *

yes

Reason for leaving previous dentist:

Is there anything else you think we should know regarding your medical history? *

yes

If yes, please provide details

To the best of your knowledge, are you in good health? *

yes

Do you have or ever had the following :

Chest Pain/Angina

Shortness of Breath

Nausea

Fainted

Do you have or ever had the following :

AIDS/ HIV Positive

Hepatitis

Tuberculosis

Asthma

Heart Attack/Condition

High Blood Pressure

Heart Murmur

Pacemaker

Mitral Valve Prolapse

Stroke

Blood Disorder

Sinusitis

Rheumatic Fever

Multiple Sclerosis (MS)

Osteoporosis

Cancer

Bronchitis

Radiation (Head/ Neck)

Epilepsy

Tumor

Stomach Ulcer

Liver Disease

Kidney Disease

Diabetes

Psychiatric disorders

Drug/Alcohol dependency

Smoke/Vape heavily

Arthritis

Thyroid Disease (__Hypo __Hyper)

Osteoarthritis

Anxiety

HPV

Emphysema

Artificial Heart Valve

Artificial Joints

Do you have or ever had the following :

Teeth Grinding/Clenching

Pain/Tenderness in Jaw

Bleeding Gum

Bad Breath

For woman only :

Take birth control pills

Pregnant

Breast Feeding Special Care

I understand that all my information will be kept strictly confidential in accordance with privacy regulations, and I authorize release as is necessary to provide proper and safe services.

I consent the Dentist and auxiliary staff to perform necessary examination, diagnostic procedures & treatments, as required, to achieve the proper level of dental care; including the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic, sedation, x-rays as indicated.

I acknowledge that I would be financially responsible for the Dental services provided regardless of insurance coverage; and, I understand payments are due when services are rendered.

Credit Card Number

Card Holder Name

Expiry Date

CVV

I understand that the appointment time given to me is reserved for me only; and as a courtesy to time and dedication of Dentist and auxiliary staff, it is my responsibility to inform the office if I need to change or cancel at least 2- business - days before my appointment. I acknowledge that if I fail to do so, I would be responsible to pay a $75 no-show or short-notice cancelation fee with no exception other than for extreme emergencies.

I certify that I have read, understood and accurately completed this form to the best of my knowledge and have not knowingly omitted any information. I also acknowledge that it is my full responsibility to inform the office of any changes prior to my upcoming appointment and fill the "Patient Update Form" once in the office.

Patient/ Guardian Full Name *

Date *

Patient (Guardian) Signature *