Are you a new patient? Fill in your information below so we know who you are! New Patient Information Form Step 1 of 8 - PERSONAL INFORMATION 12% Name* First Name Last Name Email* Home Phone*Cell Phone*Address Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*FemaleMaleOtherEmergency Contact*Emergency Contact Number*How did you hear about us?* Employer*Occupation*Do you have Dental Insurance?*YesNoName of Dental Insurance Subscriber* First Name Last Name Date of Birth of Subscriber*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Insurance Provider*Group/Plan Number*Certificate/ID Number*Do you have a Second Insurance Provider?*YesNoName of Dental Insurance Subscriber* First Name Last Name Date of Birth of Subscriber*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Insurance Provider*Group/Plan Number*Certificate/ID Number* What's your main concern right now?*When was your last dental visit?*Previous Dental Office*Do you have any Pain or Discomfort?*YesNoDo your Gums feel tender/swollen?*YesNoDo your Gums bleed?*YesNoDo you have bad breath or a bad taste in your mouth?*YesNoHave you had excessive bleeding during past dental visits?*YesNoDo you grind/clench your tooth or notice any popping/clicking noises?*YesNoDo you wear a night guard?*YesNoDo you suffer from frequent migraines?*YesNoIs snoring a problem for you?*YesNoAre you happy with the way your smile looks?*YesNo Do you have any serious Medical Conditions we should know about?* Known Medical Conditions*Please select each Medical Condition that is applicable for you!No Known Medical IssuesAlcohol/ Drug AbuseAnginaArthritisAsthmaBlood DisorderCancerChemotherapyCongenital Heart DefectDiabetesDizziness/FaintingEmphysemaEpilepsy/SeizuresFrequent HeadachesGag ReflexHay FeverHead InjuriesHearing DisabledHeart AttackHeart MurmurHemophiliaHepatitis A/B/CHigh Blood PressureHIV/AIDSJoint Replacement (hip, knee, etc)Kidney DiseaseLiver DiseaseLow Blood PressureLung Disease/ TuberculosisMental DisorderMitral Valve ProlapseMultiple SclerosisPacemakerRadiation TherapyRespiratory ProblemsSinus ProblemSTDStomach/Intestinal ProblemsStrokeThyroid DisorderUlcerOtherIf Other selected, please specify:*Do you have any allergies to medication or substances?*YesNoWhat Allergies do you have?*Are you taking any prescription medication or herbal remedies?*YesNoPlease list off your medications*Do you need to be medicated with antibiotics prior to dental treatment*YesNoDo you smoke or use chewing tobacco?*YesNoHave you ever been treated for any other illness not listed above?*YesNoAre you pregnant or nursing?*YesNoHow far along is your pregnancy?*YesNoAre you nursing?*YesNo Have you recently been under the care of a physician?*YesNoName of Physician*Physician's Number*When was your last visit with the physician?*Current Health Condition*ExcellentGoodFairPoor Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we make of your protected health information.Consent*I acknowledge and agree to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider its contents. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Email and Text Message Consent: We now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging. We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.Consent*I acknowledge that I have read and understood the above statement on emails and text messages. Should I have any questions, I can contact the practice at any time. I hereby give permission to send messages to me via email and/or text messaging as a means of communication or information distribution from our clinic. Have anymore information you want to tell us?Consent* I affirm that the information that I have given is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes to my health or medical status. I authorize Dental Now Panorama to preform any necessary dental services that I may need.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.