Dr. Anna Isaacs Dentistry | New Patient Form Mobile

Patient Information

Patient Name *

First

Last

Name of Parent/Legal Guardian (if applicable):

First

Last

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Sex: *

M
F
Other

Date of Birth: *

Email: *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number (Cell) *

Home/Other *

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Occupation / School: *

Employer / company: *

Emergency contact name: *

First

Last

Phone Number: *

Relationship: *

How did you hear about us? *

Insurance Information

Insurance: *

Yes
No

if yes, Insurance Provider: *

Subscriber Name *

Date of birth: *

Relationship to Patient: *

Self
Spouse
Child
Other

Group/Policy #: *

Certificate/ID #: *

Please note we only accept primary insurance; you are responsible for submitting to any secondary insurance.

General Information

Previous Dentists Name: (optional)

Approximate Date of Your Last Hygiene Visit:

What is the reason for your visit today? *

Do you have an aesthetic concern about your smile? *

Is there anything about your previous dental experience that we should be aware of? *

Dental History

Please indicate if you have any of the following:

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Medical History

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Family Doctor:

Pharmacy:

Have you ever had any serious illness or operation? *

Yes
No

if yes, what, and when? *

Have you ever been tested for sleep apnea? *

Yes
No

If yes, what was the diagnosis? *

If applicable;

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Do you smoke? *

Yes
No

if yes: *

Cigarettes
Vape
Marijuana
Chewing tobacco

Do you use recreational drugs? *

Yes
No

if yes, what? *

Have you ever been advised by a physician to take antibiotics before dental treatment? *

Yes
No

Medication

Medication (including vitamins)

Reason for taking?

Medication

Reason for taking?

Medication

Reason for taking?

Medication

Reason for taking?

Allergies

Penicillin *

Yes
No

Latex *

Yes
No

Codeine *

Yes
No

Ibuprofen/Advil *

Yes
No

Other (Please list ALL other allergies):

Please indicate where you do or do not have any of the following conditions:

Tuberculosis *

Yes
No

Heart problems *

Yes
No

if yes, type:

Stroke *

Yes
No

Arthritis rheumatism *

Yes
No

Artificial heart valve *

Yes
No

Epilepsy *

Yes
No

Fainting *

Yes
No

Asthma/respiratory disease *

Yes
No

Bleeding abnormally/Hemophilia *

Yes
No

HIV/AIDS *

Yes
No

Autism *

Yes
No

Congenital heart lesions *

Yes
No

if yes, type:

Artificial joints, pins etc. *

Yes
No

Stomach or duodenal ulcer *

Yes
No

Blood disease *

Yes
No

if yes, type:

Kidney disease *

Yes
No

if yes, type:

Liver disease *

Yes
No

if yes, type:

Cancer *

Yes
No

if yes, type:

Chemotherapy/Radiation *

Yes
No

Rheumatic/Scarlet fever *

Yes
No

Head/Neck injury *

Yes
No

if yes, type:

Pacemaker *

Yes
No

Autoimmune disorder *

Yes
No

if yes, type:

Drug dependency *

Yes
No

Alcohol dependency *

Yes
No

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Hepatitis *

Yes
No

if yes, type:

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Please list any additional medical conditions that may not be listed above:

Authorization and Release *

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 CONSENT TO THE TAKING OF RADIOGRAPHS AND PHOTOGRAPHS BEFORE, DURING AND AFTER TREATMENT ON MY BEHALF OR MY DEPENENTS. 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.

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Full name of Patient/legal Guardian of Minor: *

Date *

(506) 848 9191

118 Hampton Rd

New Patient Form

Patient Information

Insurance Information

General Information

Dental History

Medical History

Medication

Allergies

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