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PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

NEW PATIENT HEALTH HISTORY FORM

Preferred Pronouns

He/Him/His

She/Her/Hers

They/Them/Theirs

Other

Prefer not to specify

I understand that Urban Smiles is a scent free office, and I will refrain from wearing scented products prior to visiting Urban Smiles

I understand

How did you hear about our office?

DENTAL INFORMATION

In the following sections, please select whichever applies. Your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during you initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

MEDICAL INFORMATION

Dental professionals primarily treat the area in and around your mouth, but since your mouth is part of your body, any medication you are taking and your health History have a important relationship with your Dental Treatment. Please answer the following questions:

Additional Questions

Are you or could you be pregnant?

Yes

No

If yes, what is the expected delivery date?

Are you taking birth control pills?

Yes

No

Health History

Please go over the following section and indicate which of the following you have or have had. If you need to add any further information, please enter it at the bottom of this section.

Insurance Info

Do you have dental coverage through more than one benefits plan?

Yes

No

I understand that any portion not paid by my primary benefits plan becomes my responsibility to pay after 45 days.

Yes

No

Would you like to pay for your treatment to earn points on your credit card and be reimbursed by your insurer, rather than have your insurance plan pay us directly?

Yes

No

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

If booking on behalf of a minor: Please list any medical conditions or illnesses the child has recently had. This can include Measles, Strep Throat, Tonsillitis.

Recall frequency

Dollar Limit on Insurance Policy

Percentage for Major Coverage

Percentage for Basic Coverage

Credit Card Number and Expiry date and Security Code from back of card

I consent to allow my photo's taken to be used for dental records and research purposes.

Yes

No

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered.
I understand that providing incorrect information can be dangerous to my health.
I 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 payors, and/or health practitioners..
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I understand that during the course of the procedure(s), unforeseen conditions may arise which necessitate procedures different from those contemplated. I, therefore, consent to the performance of additional procedure(s).
I understand that I am responsible for all fees regardless of insurance coverage.
I also understand that as treatment progresses the above fees may have to be adjusted, but that I will be informed of these adjustments and how they will affect my payment.
In the event that my payments are not received within 30 days of their due date, I agree to pay all costs of collections, including, but not limited to reasonable attorney's fees.

I understand that there is a fee if I do not provide 2 business days notice to change an appointment.

Yes

No