Dentists At Metrotown – Health History Form Your information is encrypted and processed through HITRUST CSF certified technology for PIPEDA compliance. Digital Health Form "*" indicates required fields Patient InformationFirst Name:* Last Name:* Middle Name: Date of Birth* MM slash DD slash YYYY Sex:*SelectMaleFemaleOtherHow did you first find us?*SelectFacebookFriend/FamilyGoogle SearchInstagramPassed ByWord Of MouthYelpZocDocEmail:* Mobile Number:*Home Number:Address:* City:* Province:* Postal code:* What is the reason for your visit?*Employer or SchoolEmployer or School Name: Occupation: PhoneEmergency ContactFull Name:* Mobile Phone*Relationship* Billing & Dental InsuranceWho is responsible for payment?*SelectI amSomeone elseResponsible Party's InformationFull Name:* Mobile:*Email:* Relationship:* Address:* City* Province:* Postal Code:* Do you have dental insurance?*SelectYesNoUpload your dental insurance card:Front side*Accepted file types: jpg, pdf, png, Max. file size: 4 MB.Back side*Accepted file types: jpg, pdf, png, Max. file size: 4 MB.Insurance carrier:* Subscriber ID #:* Group #:* Are you the policy holder?:*YesNoInclude the policy owner's information:*First Name:* Last Name:* Date of Birth* MM slash DD slash YYYY Insurance carrier: Subscriber ID #:* Group #:* Insurer phone #:*Employer:* Dental History Date of Last Dental Exam: MM slash DD slash YYYY Date of Last Dental X-Rays: MM slash DD slash YYYY Brushing: Flossing: Do you grind your teeth?SelectYesNoHave you had orthodontic (braces) treatment?SelectYesNoHave you had gum treatment?SelectYesNoCheck only those that apply: Are you currently experiencing any of the following conditions?Bad Breath Bad Breath Difficulty Chewing Difficulty Chewing Loose Teeth Loose Teeth Sensitive Teeth to Pressure Sensitive Teeth to Pressure Bleeding Gums Bleeding Gums Difficulty Opening/Closing Mouth Difficulty Opening/Closing Mouth Mouth Pain Mouth Pain Sensitive Teeth to Sweets Sensitive Teeth to Sweets Blisters on Mouth Blisters on Mouth Dry Mouth Dry Mouth Mouth Sores Mouth Sores Swollen Gums Swollen Gums Broken Fillings Broken Fillings Ear Pain Ear Pain Sensitive Teeth to Cold Sensitive Teeth to Cold "Other" not listed? "Other" not listed? Clicking Jaw Clicking Jaw Jaw Pain Jaw Pain Sensitive Teeth to Heat Sensitive Teeth to Heat Patient Medical HistoryPrimary Care Physician Name: Phone Number:Website: Are you in good health?*YesNoPlease explain your condition:* Check only those that apply: Do you have or have had any of the following?AIDS/HIV AIDS/HIV Bowel Disorder Bowel Disorder High Blood Pressure High Blood Pressure Rheumatic Fever Rheumatic Fever Alcoholism Alcoholism Cancer Cancer High Cholesterol High Cholesterol Sinus Problems Sinus Problems Allergies Allergies Depression Depression Kidney Disorder Kidney Disorder Skin Disorder Skin Disorder Anemia Anemia Diabetes Diabetes Liver Disorder Liver Disorder Stomach Reflux/Ulcers Stomach Reflux/Ulcers Anxiety Anxiety Eating Disorder Eating Disorder Lung Disease Lung Disease Stroke/TIA Stroke/TIA Arthritis Arthritis Epilepsy Epilepsy Lupus Lupus Substance Abuse Substance Abuse Asthma Asthma Hay Fever Hay Fever Measles Measles Thyroid Problem Thyroid Problem Bleeding Disorder Bleeding Disorder Heart Disease Heart Disease Migraine Headaches Migraine Headaches Tuberculosis Tuberculosis Blood Disease Blood Disease Heart Problem Heart Problem Osteoporosis Osteoporosis Venereal Disease / STD Venereal Disease / STD Bone/Joint Disease Bone/Joint Disease Hepatitis Type A, B or C Hepatitis Type A, B or C Rheumatic Fever Rheumatic Fever "Other" not listed? "Other" not listed? Have you ever been hospitalized?*SelectYesNoPlease explain the reason for your hospitalization:* Check only those that apply: Are you currently taking any of the following medications? Analgesics (Pain Killers, Aspirin, Codeine) Antibiotics Sulfa Drugs Antihistamines Blood Thinners Digitalis or Drugs For Heart Trouble Insulin, Orinase Meds for High Blood Pressure Nitroglycerin Sedatives (Sleeping Pills, Barbiturates) Steroids (Cortisone) Tranquilizers "Other" not listed? Check only those that apply: Are you allergic, or have reacted badly to any of the below medications? Adhesive Tape Antibiotics Aspirin Barbiturates (Sleeping Pills) Codeine Iodine Adhesive Tape Antibiotics Aspirin "Other" not listed? LifestyleDo you drink caffeine?*SelectYesNo# of drinks per day* Do you smoke?*SelectYesNoHow many years? Packs per week?* Do you drink alcohol?*SelectYesNo# of drinks per day* Do you use recreational drugs?*SelectYesNo# of times per week* Consent for Services We would like to welcome you to our dental office with state of the art facility. We strive to provide the best possible dental care to you in the most personalized and comprehensive manner. Here are the highlights of our office policy. CANCELLATION POLICY: We operate with scheduled appointments only, and require a 24-hour advance notice of a cancellation or change to avoid a cancellation fee of $75. This policy is in place out of respect for our doctors and patients. Cancellations with less than 24-hour notice are difficult to fill. By giving last-minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot. INSURANCE ACCURACY: It is your responsibility and obligation to provide our office with current and accurate insurance information each time you are seen here. If incorrect information is given, there will be higher chances for insurance denial and you will be responsible for all charges not covered by insurance. INSURANCE COVERAGE: Eligibility of insurance plan DOES NOT MEAN a guarantee of coverage. We will do our best to collect your insurance information and provide complimentary insurance breakdown to you for your convenience. However, you are responsible for all unpaid portion of your treatments. ACKNOWLEDGMENT CONSENT FOR SERVICES*Select✅ I have read and understand the Cancellation Policy, Insurance Accuracy, and Insurance Coverage.Patient First Name:* Patient Last Name:* Relationship to patient:* Supplemental Informed Consent (Covid-19) Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “coronavirus”, at any time or in any place. Be assured that we continue to follow state and federal regulations as well as recommended universal personal protective equipment (PPE) and disinfection protocols to limit transmission of all diseases in our office. Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be exposed at your gym, grocery store, or favorite restaurant. Nationwide social distancing has reduced the transmission of the coronavirus. Although we have taken measures to enable social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dental healthcare team members, and sometimes other patients at all times. Although exposure is unlikely, do you accept the risk and consent to treatment?*SelectYesNoCOVID-19 Patient Screening Form1) Are you over 60 years of age?* Yes No 7) Are you experiencing repeated shaking with chills?* Yes No 2) Do you have a preexisting condition such as lung disease, heat disease, diabetes, kidney disease, or an autoimmune disorder?* Yes No 8) Do you have muscle aches?* Yes No 3) Are you experiencing shortness of breath or trouble breathing?* Yes No 9) Are you experiencing gastrointestinal changes?* Yes No 4) Do you have a temperature of 100.4℉ or higher?* Yes No 10) Have you noticed a loss of smell or taste?* Yes No 5) Are you experiencing a sore throat?* Yes No 11) Have you had contact with a known or suspected COVID-19-positive person?* Yes No 6) Are you coughing?* Yes No 12) In the last 14 days, have you traveled to an area that has a high incidence of COVID-19?* Yes No Acknowledgement By signing this form you acknowledge that you have answered the Health History form accurately and that the information you have provided is to best of your knowledge, that you agree and understand the Consent for Services.Signer First Name:* Signer Last Name:* Today's date:* MM slash DD slash YYYY Use your finger or mouse to sign in the box below.*EmailThis field is for validation purposes and should be left unchanged.
