Patient Registration Form Patient Information *All fields requiredWelcome to Cedarbrae Dental. We look forward to getting to know you, your family, and your friends and caring for your dental health, with the goals of high quality and gentle dentistry in mind. We treat all of our patients in the same manner as we would treat our families and ourselves. We will present you with your diagnosis and treatment options, honestly and openly, to help you make confident choices. We are proud our self and friendly environment, dependable and punctual services.Salutation*Mr.Mrs.Ms.Dr.First Name* Last Name* Preferred Name Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital Status* Registering for child?* Yes No Person responsible for account:* Other parental consent required:* Yes No Mother’s name* Contact Number* Father’s name* Contact Number* Contact InformationEmail* Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home PhoneCell Phone*Work PhoneExt. In case of emergency, please notify:Name* Relation* Home Phone*Cell Phone*Work PhoneContact OptionsI prefer appointment reminders by* Phone SMS Email Whom may we thank for referring you? Are any other members of your family patients at our practice?* Yes No Please list:Insurance Information* Yes, insurance applies to me No, insurance does not apply to me Please complete the following if you have dental insuranceName of insured/subscriber* Date of Birth* MM slash DD slash YYYY Patient's relationship to subscriber* Self Spouse Child Place of employment* Insurance Company* Policy/Group#* Certificate/ID#* I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations* Yes Dental History Why have you come to the dentist today?* Are you currently in pain?* Yes No Please Explain:*Do you brush twice a day?* Yes No Do you floss daily?* Yes No Do you use mouthwash?* Yes No Other:* Do you have any of the following?Bleeding gums* Yes No Not Sure Food Caught in your teeth* Yes No Not Sure Sensitive teeth* Yes No Not Sure Loose teeth* Yes No Not Sure How would you rate your previous dental experience? 1. Being Relaxed 5. Extremely NervousAre you happy with the appearance of your teeth?* Yes No Not Sure What would you change?Previous Dentist: Last Visit Date MM slash DD slash YYYY Reasons:Medical HistoryPhysician's Name: Address: Phone Number:Specialist's Name: Address: Phone Number:Specialist's Name: Address: Phone Number:Have you been under medical care within the past two years?* Yes No Reasons:*When was your last physical exam?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Result:When was your last visit to a Physician?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Reason:Do you have or have you ever experienced the following?Abnormal bleeding* Yes No Not Sure Abnormal bruising* Yes No Not Sure Blood transfusion* Yes No Not Sure Blood disorder* Yes No Not Sure Hemophilia* Yes No Not Sure Liver disease* Yes No Not Sure Jaundice* Yes No Not Sure Hepatitis A B C* Yes No Not Sure Sickle cell anemia* Yes No Not Sure Anemia* Yes No Not Sure Prostate problems* Yes No Not Sure Head/neck injuries* Yes No Not Sure Headaches/migraines* Yes No Not Sure Sinus problems* Yes No Not Sure Glaucoma/Cataract* Yes No Not Sure Artificial joints* Yes No Not Sure Seizures/Epilepsy* Yes No Not Sure Arthritis/Rheumatism* Yes No Not Sure Lupus* Yes No Not Sure Organ transplant* Yes No Not Sure Colitis/Ulcers* Yes No Not Sure Ever hospitalized* Yes No Not Sure Alcohol / drug abuse* Yes No Not Sure Steroid therapy* Yes No Not Sure Cancer* Yes No Not Sure Radiation treatment* Yes No Not Sure Chemotherapy* Yes No Not Sure Venereal disease* Yes No Not Sure Herpes* Yes No Not Sure Immune problems* Yes No Not Sure HIV/AIDS* Yes No Not Sure Mitral Valve Prolapse* Yes No Not Sure Psychological problems* Yes No Not Sure Malignant hyperthermia* Yes No Not Sure Tuberculosis (TB)* Yes No Not Sure Persistent cough* Yes No Not Sure Emphysema* Yes No Not Sure Asthma* Yes No Not Sure Lung problem* Yes No Not Sure Shortness of breath* Yes No Not Sure Sleep apnea* Yes No Not Sure Thyroid problems* Yes No Not Sure Kidney problems* Yes No Not Sure Diabetes* Yes No Not Sure Stroke* Yes No Not Sure High/ low blood pressure* Yes No Not Sure High cholesterol* Yes No Not Sure Congenital heart defect* Yes No Not Sure Heart murmur* Yes No Not Sure Heart surgery* Yes No Not Sure Heart attack/Angina* Yes No Not Sure Pacemaker* Yes No Not Sure Swollen ankles, feet, or hands* Yes No Not Sure Rheumatic fever* Yes No Not Sure Artificial valves* Yes No Not Sure Pre-medication with antibiotics for dental treatment* Yes No Not Sure BP: HR: Others, Please Explain:Are you taking any prescription / over the counter drugs or herbal supplements?* Yes No Please list them:Please select your allergy(ies): Aspirin Barbiturates Codeine Anaesthesia Erythromycin Penicillin Clindamycin Sulfa drugs Tetracycline Injections Jewelry/metals Latex Other Please Specify:Women Only:Are you taking any birth Control Pills? Yes No Are you Pregnant? Yes No Number of months? Consent and Policies I affirm that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform the office of any changes in my medical status. I acknowledge that my dental benefits are my responsibility I understand that I am responsible for payment of services rendered for my dependents and myself. Payment is due on the day of service rendered unless otherwise financially arranged. a fee of $45.00 is changed per NSF cheque. My appointments are considered confirmed when scheduled. Cedarbrae Dental requires a notice of 2 business days for any changes to my reserved appointment. A fee of $50.00 per appointment is changed for no-show, or short notice cancellation. I have reviewed the information that explains how Cedarbrae Dental will use my personal information. and the steps Cedarbrae Dental will take to protect my information. I agree that Cedarbrae Dental can collect, use and disclose personal information about my dependents & myself as set out in the information about the privacy policies. I can ask to see these policies at any time. I give consent to that dental staff to provide the necessary diagnosis and treatment, and authorize the release of my information and my dependents to information my dental insurance company/plan administrator for Electronic Dental Insurance (EDI) submission. We are pleased to answer any questions you may have or receive your feedback thank you for joining our dental family at Cedarbrae DentalDate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature:*NameThis field is for validation purposes and should be left unchanged.
