Welcome To Name(Required) First Last Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone(Required)Cell Phone(Required)Work Phone(Required)Employer(Required) Date of Birth(Required) MM slash DD slash YYYY Email Address(Required) Do you use Dental Insurance?(Required) Yes No Employer(Required) Birthday of Policy holder if not yourself :(Required) MM slash DD slash YYYY Name of Insurance Company:(Required) Plan ID No.(Required) Subscriber No.(Required) Did you find us by?(Required) Google Search/Website Print Advertisement Our Signs Which method is the best and MOST RELIABLE way to get in touch with you (you are sure to get the message promptly). PLEASE CIRCLE and note if there are specific times or days.(Required) HOME PHONE WORK PHONE CELL PHONE TEXT MESSAGING EMAIL Specific times or days:(Required) EMERGENCY CONTACT NAME(Required) PHONE No.(Required)Medical Conditions/Diagnosis:(Required) Please note: we are pleased to provide our patients with assignment (direct billing) from the insurance provider. It may be necessary for you to collect the details of your policy due to privacy. The more information we have, the more accurately we will be able to estimate possible out of pocket expenses for your required treatment. Dr. Singer will thoroughly review your medical history, please list the following:If you were referred by an existing patient, who can we thank?(Required) Prescription Medication:(Required) Allergies (Food, Medicine or other):(Required) Surgeries:(Required) Physician/Specialist Name (Date of last Visit):(Required) How can we help you today?(Required) COMREHENSIVE CARE/NEW PATIENT SPECIFIC CONCERN Missing teeth that should be replaced to preserve bone and tooth position.(Required) Yes No I have spontaneous/unprovoked/ tooth pain, or pain that wakes me from sleep.(Required) Yes No I have pain in my jaw joint. (Head/Neck aches associated).(Required) Yes No I have pain when biting into food that is room temperature.(Required) Yes No I have pain to cold or hot food or drinks.(Required) Yes No Food catches between my teeth.(Required) Yes No I would like my teeth to be straiter/more aligned.(Required) Yes No I would like my teeth to be shaped differently.(Required) Yes No I would like my teeth to be WHITER.(Required) Yes No I snore and/or sleep poorly.(Required) Yes No Any other concerns:(Required) Yes No Is there anything we can do to make your appointments more comfortable or convenient for you?(Required) Yes No Please remember to advise us of any changes.Date(Required) MM slash DD slash YYYY Signature:(Required)Dr. Signature:(Required)All information is kept strictly confidential in accordance with privacy regulations.CommentsThis field is for validation purposes and should be left unchanged.
