New Patient Form

WELCOME TO KINGSLAND FAMILY DENTAL CENTRE

"*" indicates required fields

Patient's Legal Name*

Prefix First Last

Prefer to be Called

Email*

Date of Birth*

Gender*

Marital Status*

Cell Phone*

Patient's Address*

Street Address City Province Postal Code

Do you have dental insurance?*

Yes

Primary Insurance

Policy Holder*

Prefix First Last

Insurance Company*

Employer*

Group/Policy Number*

Identification/Certificate Number*

Secondary Insurance

Policy Holder

Prefix First Last

Insurance Company

Employer

Group/Policy Number

Identification/Certificate Number

Referral Information

Who can we thank for referring you to our office?

EMERGENCY CONTACT INFORMATION

PERSON WE MAY CONTACT IN CASE OF AND EMERGENCY (OTHER THAN YOUR FAMILY HOME)

Name*

Relationship*

Cell Phone*

Medical History

Doctor's Office Number

Name of physician

Most recent physical examination

What is your estimate of your general health?

Excellent

Good

Fair

Poor

DO YOU HAVE or HAVE YOU EVER HAD:

Hospitalization for illness or injury*

Yes

Please add further details

An allergic or bad reaction to any of the following:

Please add further details

Heart problems, or cardiac stent within the last six months*

Yes

Please add further details

History of infective endocarditis*

Yes

Please add further details

Artificial heart valve, repaired heart defect (PFO)*

Yes

Please add further details

Pacemaker or implantable defibrillator*

Yes

Please add further details

Orthopedic implant (joint replacement)*

Yes

Please add further details

Rheumatic or scarlet fever*

Yes

Please add further details

High or low blood pressure*

Yes

Please add further details

A stroke (taking blood thinners)*

Yes

Please add further details

Anemia or other blood disorder*

Yes

Please add further details

Prolonged bleeding due to a slight cut (INR > 3.5)*

Yes

Please add further details

Pneumonia, emphysema, shortness of breath, sarcoidosis*

Yes

Please add further details

Tuberculosis, measles, chicken pox*

Yes

Please add further details

Asthma*

Yes

Please add further details

Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)*

Yes

Please add further details

Kidney disease*

Yes

Please add further details

Liver disease*

Yes

Please add further details

Jaundice*

Yes

Please add further details

Thyroid, parathyroid disease, or calcium deficiency*

Yes

Please add further details

Hormone deficiency*

Yes

Please add further details

High cholesterol or taking statin drugs*

Yes

Please add further details

Diabetes*

Yes

Please add further details

Type

HbA1c =

Stomach or duodenal ulcer*

Yes

Please add further details

Digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)*

Yes

Please add further details

Osteoporosis/osteopenia (i.e. taking bisphosphonates)*

Yes

Please add further details

Arthritis*

Yes

Please add further details

Autoimmune disease*

(i.e. rheumatoid arthritis, lupus, scleroderma)

Yes

Please add further details

Glaucoma*

Yes

Please add further details

Contact lenses*

Yes

Please add further details

Head or neck injuries*

Yes

Please add further details

Epilepsy, convulsions*

(seizures)

Yes

Please add further details

Neurologic disorders*

(ADD/ADHD, prion disease)

Yes

Please add further details

Viral infections and cold sores*

Yes

Please add further details

Any lumps or swelling in the mouth*

Yes

Please add further details

Hives, skin rash, hay fever*

Yes

Please add further details

STI/STD/HPV*

Yes

Please add further details

Hepatitis*

Yes

Please add further details

HIV/AIDS*

Yes

Please add further details

Tumor, abnormal growth*

Yes

Please add further details

Radiation therapy*

Yes

Please add further details

Chemotherapy, immunosuppressive medication*

Yes

Please add further details

Emotional difficulties*

Yes

Please add further details

Psychiatric treatment*

Yes

Please add further details

Antidepressant medication*

Yes

Please add further details

Alcohol/recreational drug use*

Yes

Please add further details

ARE YOU:

Presently being treated for any other illness*

Yes

Please add further details

Aware of a change in your health in the last 24 hours*

(i.e. fever, chills, new cough, or diarrhea)

Yes

Please add further details

Taking medication for weight management*

Yes

Please add further details

Taking dietary supplements*

Yes

Please add further details

Often exhausted or fatigued*

Yes

Please add further details

Experiencing frequent headaches*

Yes

Please add further details

A smoker, smoked previously or use smokeless tobacco*

Yes

Please add further details

Considered a touchy/sensitive person*

Yes

Please add further details

Often unhappy or depressed*

Yes

Please add further details

Taking birth control pills*

Yes

Please add further details

Currently pregnant*

Yes

Please add further details

Diagnosed with a prostate disorder*

Yes

Please add further details

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.

(i.e. Botox, Collagen Injections)

MEDICATION, SUPPLEMENTS, VITAMINS

List all medications, supplements, and or vitamins taken within the last two years.

Drug

Purpose

Click the + icon on the right to add more rows.

Dental History

How would you rate the condition of your mouth?*

Previous Dentist

How long were you been a patient?

Date of most recent dental exam

Date of most recent x-rays

Date of most recent treatment

I routinely saw my previous dentist every:

WHAT IS YOUR IMMEDIATE CONCERN?

PERSONAL HISTORY

Are you fearful of dental treatment?*

Yes

How fearful, on a scale of 1 (least) to 10 (most)

Have you had an unfavorable dental experience?*

Yes

Please add further details

Have you ever had complications from past dental treatment?*

Yes

Please add further details

Have you ever had trouble getting numb or had any reactions to local anesthetic?*

Yes

Please add further details

Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?*

Yes

Please add further details

Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?*

Yes

Please add further details

GUM AND BONE

Do your gums bleed or are they painful when brushing or flossing?*

Yes

Please add further details

Have you ever been treated for gum disease or been told you have lost bone around your teeth?*

Yes

Please add further details

Have you ever noticed an unpleasant taste or odor in your mouth?*

Yes

Please add further details

Is there anyone with a history of periodontal disease in your family?*

Yes

Please add further details

Have you ever experienced gum recession?*

Yes

Please add further details

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?*

Yes

Please add further details

Have you experienced a burning or painful sensation in your mouth not related to your teeth?*

Yes

Please add further details

TOOTH STRUCTURE

Have you had any cavities within the past 3 years?*

Yes

Please add further details

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?*

Yes

Please add further details

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?*

Yes

Please add further details

Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?*

Yes

Please add further details

Do you have grooves or notches on your teeth near the gum line?*

Yes

Please add further details

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?*

Yes

Please add further details

Do you frequently get food caught between any teeth?*

Yes

Please add further details

BITE AND JAW JOINT

Do you have problems with your jaw joint?*

(pain, sounds, limited opening, locking, popping)

Yes

Please add further details

Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?*

Yes

Please add further details

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*

Yes

Please add further details

In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?*

Yes

Please add further details

Are your teeth becoming more crooked, crowded, or overlapped?*

Yes

Please add further details

Are your teeth developing spaces or becoming more loose?*

Yes

Please add further details

Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?*

Yes

Please add further details

Do you place your tongue between your teeth or close your teeth against your tongue?*

Yes

Please add further details

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*

Yes

Please add further details

Do you clench or grind your teeth together in the daytime or make them sore?*

Yes

Please add further details

Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?*

Yes

Please add further details

Do you wear or have you ever worn a bite appliance?*

Yes

Please add further details

SMILE CHARACTERISTICS

Is there anything about the appearance of your teeth that you would like to change?*

(shape, color, size)

Yes

Please add further details

Have you ever whitened (bleached) your teeth?*

Yes

Please add further details

Have you felt uncomfortable or self conscious about the appearance of your teeth?*

Yes

Please add further details

Have you been disappointed with the appearance of previous dental work?*

Yes

Please add further details

X-Rays Release Form

I am requesting copy of my dental x-rays to be emailed to Kingsland Family Dental Care*

Prefix Your First Name Your Last Name

Cell Phone*

Email*

Name of previous dental office / Dentist :*

Assignment & Release*

I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claim, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively "My Images") , and (5) my dentist's use of My images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the "Uninsured Costs") in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment. If the above named Patient is a minor or unable to pay the his/her Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient's dentist in accordance with his/her payment terms and policies (PLEASE SIGN).*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

64782

WELCOME TO KINGSLAND FAMILY DENTAL CENTRE

Primary Insurance

Secondary Insurance

Referral Information

EMERGENCY CONTACT INFORMATION

Medical History

DO YOU HAVE or HAVE YOU EVER HAD:

ARE YOU:

MEDICATION, SUPPLEMENTS, VITAMINS

Dental History

PERSONAL HISTORY

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

X-Rays Release Form

From all of us at Kingsland Family Dental, we look forward to seeing you soon.

WE LOOK FORWARD TO MEETING YOU AT KINGSLAND FAMILY DENTAL CARE - ALL NEW PATIENTS WELCOME!

Our Services

Quick links

Our Hours

Disclaimer

Monday:	10:00 am – 6:00 pm
Tuesday:	7:00 am – 3:00 pm
Wednesday:	7:00 am – 3:00 pm
Thursday:	10:00 am – 6:00 pm
Friday:	Closed
Saturday:	Closed
Sunday’s & Holidays:	Closed