ICONIC Dentisty + Aesthetics New Patient Form

First Name

Last Name

Date of birth *

Address

Street Address *

City *

Country -

Phone *

Email *

ID/DP/ PP #: *

Emergency Contact Name & Relationship *

Emergency Contact Address *

Emergency Contact Phone *

Dental History

How would you rate the condition of your mouth? *

Excellent

Good

Fair

Poor

Previous Dentist

How long had you been a patient?

Date last seen by a Dentist

What is your immediate concern? *

PLEASE ANSWER YES OR NO TO THE FOLLOWING AND GIVE ANY DETAILS WHERE NECCESSARY:

DENTAL EXPERIENCE

Are you fearful of dental treatment? *

Yes

No

How fearful are you on a scale of 1 (least) to 10 (most)?

Have you had a bad experience/ complications/ trouble getting numb/reactions to anaesthetics? If Yes, Please Explain. *

Have you had any teeth removed? If yes, please explain *

AESTHETIC

Is there anything about the appearance of your teeth that you wish to change? If yes, please explain *

Have you ever whitened/ bleached your teeth? If yes, please explain. *

Have you had orthodontic treatment/ brace? Yes / No *

Yes

No

Have you felt uncomfortable or self-conscious about the appearance of your teeth? If yes, please explain *

Have you been disappointed with the appearance of previous dental work? If yes, please explain *

Have you had any facial or body cosmetics work undertaken? If yes, please explain *

OCCLUSION/TMJ

Do you have any problems with your jaw joint? (pain, sounds, opening, locking, muscular pain, headaches): If yes, please explain *

Do you chew ice, bite your nails, clench or grind your teeth or have any other chewing habits? If yes, please explain *

Are your teeth crowding or have spaces?

Yes

No

Does your bite make your teeth fit together well? *

Yes

No

Unsure

Do you have any problems with sleep, sleep apnea, or night teeth grinding? If yes, please explain *

Do you wear or ever had to wear a bite appliance or had your bite adjusted? If yes, please explain *

ODONTOGENIC

Have you had any cavities in the last 3 years? If yes, please explain. *

Does the amount of saliva in your mouth seem too little or any difficulty swallowing food? If yes, please explain *

Have you noticed any holes, grooves or notches on your teeth? If yes, please explain *

Are any teeth sensitive to hot or cold, biting, eating sweet food or brushing? If yes, please explain *

Have you ever broken teeth, chipped teeth or had tooth ache or cracked fillings? If yes, please explain *

Do you floss regularly? *

Yes

No

Do you often get food stuck between your teeth? *

Yes

No

PERIODONTAL

Do your gums bleed when brushing, flossing or eating? If yes, please explain *

Have you ever been treated for gum disease or been told you have lost bone around your teeth? If yes, please explain *

Have you ever noticed an unpleasant taste or odour in your mouth? If yes, please explain *

Is there any family history of periodontal/ gum disease in your family? If yes, please explain *

SOCIAL HISTORY

Do you smoke cigarettes or any illicit drugs? *

Yes

No

How many years have you been a smoker?

How many packs of cigarettes do you have a day?

Do you drink alcohol? *

Yes

No

How often do you drink alcohol?

MEDICAL HISTORY

Physician's Name

Physician's Phone

Date of Last Visit

Have you had any serious illnesses or operations? If yes, describe *

WOMEN

Are you pregnant? *

Yes

No

Nursing?

Yes

No

Taking birth control pills?

Yes

No

List medications you are currently taking

YOUR FAVORITE THINGS

Allergies or Dietary Restrictions

Birthday: {Favorite Things}

Color

Snacks

Candy

Coffee Drink/Place

Baked Good

Fruit

Hobbies

Restaurants/Places to Shop

Dislikes

If you were referred, or heard about us in another manner not listed please specify who referred you or where you heard about us here...

DECLARATION: To the best of my knowledge, the above information is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child ever have a change in health.

I agree

RELEASE OF INFORMATION: I authorize the release of any medical or other information necessary to verify benefits, process claims, or provide appropriate care or related services provided by ICONIC DENTISTRY + AESTHETICS LTD or its Agents.

I consent

Patient Signature

Clear

Date