Business information

Please print neatly and complete as accurately as possible: EMAIL ADDRESS (FOR APPOINTMENT REMINDERS AND BUSINESS CORRESPONDENCE) D E N T A L I N S U R A N C E I N F O R M A T I O NPayment for all services is required at the end of each appointment. Please be aware of any limitations to your plan since responsibility for your account belongs to you. We will gladly assist you in better understanding your insurance plan, however, you may still need to contact your insurer directly. We will also prepare and if possible submit insurance forms electronically. Please visit our website for more information about your dental insurance.
Your company will provide you with a Dental Benefit card. If you provide us with this card we will ensure that all data is properly transcribed to allow for electronic submission in most cases.
A U T H O R I Z A T I O N A N D R E L E A S EI authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health care practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services.
I authorize release to my dental benefits plan administrator, information contained in claims submitted electronically.
CANCELLATION POLICYWhen patients give advance notice of their need to cancel a scheduled appointment, this time can be allocated to those patients in need of urgent dental treatment. If less than TWO BUSINESS days notice is given, a missed appointment fee of $100.00 per hour will be assessed. Exceptions will be made for illness or personal tragedy. Each case will be evaluated individually. Please be aware that insurance companies do not cover missed appointment fees. 2013 Dr. Troy Martin Inc 330-2425 Oak Street Vancouver British Columbia V6H 3S7 604.732.6623 M E D I C A L H I S T O R Y Q U E S T I O N N A I R E Patient Name _______________________________________ Date of Birth (Day/Month/Year) ____/____/______ Name of Physician/and their specialty ________________________________________________________________ Most recent physical examination ___________________________ Purpose _________________________________What is your estimate of your general health? Excellent Good Fair Poor The following information is required to enable us to provide you with the best possible dental care.
All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
PLEASE ANSWER YES OR NO TO THE FOLLOWING: Are you being treated for any medical condition at the present or have you been treated Has there been any change in your general health in the past year? If yes, please explain.
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? Do you have any allergies? If you answered yes, please list using the categories below: a) medicationsb) latex / rubber products / metalsc) other (e.g. hayfever, foods) Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, Do you have or have you ever had any heart or blood pressure problems? Do you have or have you ever had a replacement or repair of a heart valve, arterial stent, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital 2013 Dr. Troy Martin Inc 330-2425 Oak Street Vancouver British Columbia V6H 3S7 604.732.6623 PLEASE ANSWER YES OR NO TO THE FOLLOWING: 9. Do you have a prosthetic or artificial joint? 10. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy? 11. Have you ever had hepatitis, jaundice or liver disease? 12. Do you have a bleeding problem or bleeding disorder? 13. Do you have or have you ever had any of the following? Please check.
14. Have you ever been treated for or diagnosed with a mental illness? If yes, please explain.
15. Are there any conditions or diseases not listed above that you have or have had? If so, what? 16. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or 18. Do you smoke (tobacco or other) or chew tobacco products? 19. Are you nervous during dental treatment? 20. For women only: Are you breastfeeding or pregnant? If pregnant, what is the expected I herby certify that I have read and understand the information above, and that is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. If I ever have any change in my health, I will inform the doctor at the next dental appointment without fail. 2013 Dr. Troy Martin Inc 330-2425 Oak Street Vancouver British Columbia V6H 3S7 604.732.6623 How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist ______________________________How long have you been a patient?___________Months/Years Date of most recent dental exam ______/______/______ Date of most recent x-rays ______/______/______ Date of most recent treatment (other than a cleaning) ______/______/______I routinely see a dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinelyHow often do you brush your teeth? __________________________ Manual Electric ___________________How often do you floss your teeth? __________________________ Waxed Unwaxed Other______________Do you use any other dental hygiene tools (please list)? ______________________________________________________WHAT IS YOUR IMMEDIATE CONCERN?___________________________________________________________________IS THERE ANYTHING YOU WOULD LIKE TO CHANGE ABOUT YOUR SMILE? ________________________________________________________________________________________________________ PLEASE ANSWER YES OR NO TO THE FOLLOWING: P E R S O N A L H I S T O R Y1 Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [______] 2 Have you had an unfavorable dental experience?_______________________________________ 3 Have you ever had complications from past dental treatment? ___________________________ 4 Have you ever had trouble getting numb or had any reactions to local anesthetic? _________ 5 Did you ever have braces, orthodontic treatment or had your bite adjusted? ______________ 6 Have you had any teeth removed? ___________________________________________________S M I L E H I S T O R Y7 Is there anything about the appearance of your teeth that you would like to change?________ 8 Have you ever whitened (bleached) your teeth? ________________________________________ 9 Have you felt uncomfortable or self conscious about the appearance of your teeth? _________ 10 Have you been disappointed with the appearance of previous dental work? _______________B I T E A N D J A W J O I N T 11 Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) 12 Do you / would you have any problems chewing gum or hard foods? ______________________ 13 Have your teeth changed in the last 5 years, become shorter, thinner or worn? ______________ 14 Are your teeth crowding or developing spaces? _________________________________________ 15 Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? 16 Are you aware of clenching your teeth in the daytime or holding them together? ____________ 17 Do you have any problems with sleep or wake up with an awareness of your teeth? __________ 18 Do you wear or have you ever worn a brux appliance (night guard)? _______________________T E E T H 19 Have you had any cavities within the past 3 years? _______________________________________ 20 Does the amount of saliva in your mouth seem too little (does your mouth feel dry)? _________ 21 Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? ______ 22 Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? 23 Do you have grooves or notches on your teeth near the gum line? ________________________ 24 Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? __________ 25 Do you get food caught between any teeth? ____________________________________________ 26 Do your gums bleed when brushing or flossing? ________________________________________ 27 Have you ever been treated for gum disease or been told you have lost bone around your teeth? _____ 28 Have you ever noticed an unpleasant taste or odor in your mouth? ________________________ 29 Is there anyone with a history of periodontal disease in your family? _______________________ 30 Have you ever experienced gum recession? ____________________________________________ 31 Have you ever had any teeth become loose on their own (without an injury)?________________ 32 Have you experienced a burning sensation in your mouth? _______________________________ 2013 Dr. Troy Martin Inc 330-2425 Oak Street Vancouver British Columbia V6H 3S7 604.732.6623

Source: http://www.oakviewdental.ca/new_patient.pdf