PATIENT INFORMATION REGISTRATIONPatient Information Registration GENERAL PATIENT INFORMATIONFirst Name Initial Last Name Gender —Please choose an option—MaleFemaleOtherDate of Birth Language —Please choose an option—EnglishFrenchOtherEmail Communication Preference EmailPhoneSMSCell 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 —Please choose an option—Dental ImplantsWisdom Teeth surgeryBone GraftSurgical ExposureAll on 4Zygomatic ImplantsCorrective Jaw SurgeryApicoectomyFacial TraumaTemporo-Mandibular Joint (TMJ) DisordersCBCTSedation and General AnesthesiaOral PathologyObstructive Sleep Apnea (OSA)Same Day Surgery and ConsultationOtherOther Reason Guarantor of this Patient MEDICAL HISTORYRate your anxiety level regarding a dental surgery procedure 12345678910Weight Height Emergency ContactName Phone Number DO YOU HAVE OR HAVE YOU EVER HAD(Check the boxes that apply to your past or present situation.)Alzheimer's diseaseHIVAnemiaHepatitisAnxietyHigh blood pressureArthritisInfarct/AnginaAsthma or COPDKidney diseaseAttention Deficit /Hyperactivity Disorder (ADHD)Liver disease.Autism Spectrum Disorder (ASD)Lung problemsBronchitisLow blood pressureCancerOsteoporosisChemotherapy treatmentOther pulmonary problemsChronic CoughMental illnessCoagulation problemsNervous disordersDiabetesRadiotherapy treatmentDigestive problemsRheumatic feverEndocarditis (heart infection)Sexually transmitted diseaseEpilepsySkin diseaseFainting spellsStrokeFeverThrombophlebitisFrequent HeadachesThyroid problemsFrequent sinusitisTuberculosisFrequent sinusitisValvulopathy (trouble with heart valves)Gastrointestinal problems (ulcers or reflux)Heart murmur or cardiac malformationOTHER MEDICAL QUESTIONS OR HABITSHave you had any illness, operation or been hospitalized in the past five years? YesNoDate: If so, explain Have you been treated by a physician within the past year? YesNoHave you had a recent change in weight? YesNoDo you have any implants in your body (heart valve, knee, hip)? YesNoIf so, which implant and since when? Do you suffer or have you suffered from sleep apnea symptoms? YesNoIf so, have you ever done a polysomnography (PSG) (sleep study)? YesNoDo you drink alcohol? YesNoIf so, how many beverages per week? Do you smoke? YesNoIf so, how much per day? Since when: Do you take a birth control pill? YesNoDo you use marijuana products? YesNoIf so, how often? Do you take any medications / drugs? YesNoIf so, which ones? Are you pregnant? YesNoIf so, which trimester? Premedication before dental procedures? YesNoAre you nursing? YesNoAny other health problems you want to mention? ALLERGIES AND MEDICATIONDo you have allergies to penicillin? YesNoDo you have allergies to latex? YesNoDo you have any allergies to any medication? YesNoIf so, which ones? Have you (or a familly member) ever had complications due to general anesthesia? YesNoIf so, explain: Do you have any known food allergies? YesNoIf 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)? YesNoAre you taking blood thinners? YesNoIf so, which ones? Are you taking any herbal medicines? YesNoIf 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. 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 Name / Legal Guardian Implantology and Maxillofacial Surgery CenterWe accept new patients without a referral Book an Appointment