PATIENT INFORMATION REGISTRATION

Patient Information Registration

    GENERAL PATIENT INFORMATION

    First Name

    Initial

    Last Name

    Gender

    Date of Birth

    Language

    Email

    Communication Preference

    Cell Number

    Home Number

    Work Number

    Address

    City

    Province

    Postal code

    Country

    Healthcare number

    Healthcare expiration

    Occupation

    Referring dentist

    Family Physician

    Orthodontist

    How did you hear about us?

    Reason for consultation

    Other Reason

    Guarantor of this Patient

    MEDICAL HISTORY

    Rate your anxiety level regarding a dental surgery procedure

    Weight

    Height

    Emergency Contact

    Name

    Phone Number

    DO YOU HAVE OR HAVE YOU EVER HAD

    (Check the boxes that apply to your past or present situation.)

    OTHER MEDICAL QUESTIONS OR HABITS

    Have you had any illness, operation or been hospitalized in the past five years?

    Date:

    If so, explain

    Have you been treated by a physician within the past year?

    Have you had a recent change in weight?

    Do you have any implants in your body (heart valve, knee, hip)?

    If so, which implant and since when?

    Do you suffer or have you suffered from sleep apnea symptoms?

    If so, have you ever done a polysomnography (PSG) (sleep study)?

    Do you drink alcohol?

    If so, how many beverages per week?

    Do you smoke?

    If so, how much per day?

    Since when:

    Do you take a birth control pill?

    Do you use marijuana products?

    If so, how often?

    Do you take any medications / drugs?

    If so, which ones?

    Are you pregnant?

    If so, which trimester?

    Premedication before dental procedures?

    Are you nursing?

    Any other health problems you want to mention?

    ALLERGIES AND MEDICATION

    Do you have allergies to penicillin?

    Do you have allergies to latex?

    Do you have any allergies to any medication?

    If so, which ones?

    Have you (or a familly member) ever had complications due to general anesthesia?

    If so, explain:

    Do you have any known food allergies?

    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)?

    Are you taking blood thinners?

    If so, which ones?

    Are you taking any herbal medicines?

    If so, which ones?

    Please list all medications that you are taking:

    If necessary, include a list:

    A 48-hour notice is required when you want to cancel or change an appointment.

    Date

    Patient Name

    Patient Name / Legal Guardian

    Implantology and Maxillofacial Surgery Center

    We accept new patients without a referral