PATIENT INFORMATION

A parent or guardian will be responsible for decisions on my treatment*

Yes

No

First Name*

Middle Name

Last Name*

Address*

City*

State*

Postal Code*

Birth Date

Age*

Sex*

Male

Female

Home*

Work

Email*

Emergency Contact

Tel

Employer

Occupation

Family Doctor

Tel

Previous Dentist

Referred By

MEDICAL HISTORY

this information will remain confidential

A) Drug

Reason

B) Drug

Reason

C) Drug

Reason

D) Drug

Reason

E) Drug

Reason

F) Drug

Reason

GENERAL RELEASE

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment.I certify that all or the information I have completed is correct and that i have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as iS required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependent

Self Signature

Print name

Parent/Guardian Signature

Date

First Visit Paperwork

PATIENT INFORMATION

MEDICAL HISTORY

GENERAL RELEASE

Quinte Mall Dental

First Visit Paperwork

PATIENT INFORMATION

MEDICAL HISTORY

GENERAL RELEASE

Quinte Mall Dental

Current Patient

New Patient