Patient Intake Form

Please complete the form below to request a consultation. Our team will review your information, confirm availability, and contact you with the next steps.

Specialist-led care
Quick follow-up
Downtown Halifax

Need faster assistance? Call (902) 422-5454.

New Patient Intake Form

Patient Information

The following information is necessary for this office to provide dental care in a manner that is compatible with your general health. Although some questions may seem unrelated to your gum condition, they are associated with proper management of your oral health.

First Name(Required)

Last Name(Required)

Birth Date (M / D / Y)(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City Province Postal Code

Canadian Resident?

Yes

Health Card #

Cell Phone(Required)

Home Phone

Business Phone

Email Address(Required)

Next of Kin

Relationship

Next of Kin Phone

Dentist

Dentist Phone

Town (Dentist)

How Long? (Dentist)

Physician

Physician Phone

Town (Physician)

How Long? (Physician)

Referred By

Phone

Reason for Visit(Required)

Medical History

The following information is necessary for this office to provide dental care in a manner that is compatible with your general health.

1. Are you in good health?

Yes

2. Have you been under the care of a physician during the last 2 years?

Yes

Condition being treated

3. Date of last physical examination

MM slash DD slash YYYY

4. Have you had any serious illness or operation?

Yes

If yes, what

5. Have you been hospitalized within the last 5 years?

Yes

6. Check any of the following which you have had or have at present:

Heart Attack

Kidney Trouble

AIDS (HIV Positive)

Heart Disease or Failure

Stomach Ulcers

Liver Disease

Heart Murmur

Tuberculosis (TB)

Hepatitis

Congenital Heart Lesions

Emphysema

Yellow Jaundice

Angina Pectoris

Allergies or Hives

Blood Transfusion

Rheumatic Fever

Asthma

Haemophilia

Rheumatic Heart Disease

Hay Fever

Drug Addiction

Artificial Heart Valve

Sinus Trouble

Venereal Disease

Heart Pacemaker

Diabetes

Cold Sores

Heart Surgery

Thyroid Disease

Genital Herpes

Artificial Joint

Arthritis

Nervousness

High Blood Pressure

Rheumatism

Depression

Low Blood Pressure

Glaucoma

Psychiatric Tx.

Stroke

Epilepsy

Sickle Cell Disease

Chest Pain

Fainting

Radiation Therapy

Shortness of Breath

Bruise Easily

Chemotherapy

Swelling of Ankles

Malignant Hyperthermia

Anaemia

Respiratory Disorders

Blood Disorders

Frequent Headaches

7. Have you had abnormal bleeding with extractions, surgery, or trauma?

Yes

8. Are you allergic or have you reacted adversely to:

Local anaesthetics (Novocaine, Lidocaine, freezing, Latex)

Penicillin or other antibiotics (Sulfa drugs, etc.)

Barbiturates, sedatives, or sleeping pills

Advil or Tylenol (Ibuprofen or Acetaminophen)

Codeine or other narcotics

Latex

Other

Other allergy details

9. Are you taking any drug or medication?

Yes

If yes, what are you taking?

10. Do you smoke?

Yes

If yes, how many a day?

Do you drink alcoholic beverages?

Yes

If yes, how many a week?

Do you use illicit drugs?

Yes

11. Have you had in the past or do you presently have any disease, condition, or problem not listed above?

Yes

12. Has anyone in your family had diabetes?

Yes

13. Women: Are you pregnant?

Yes

Month?

14. Problems of the jaw. Have you ever experienced:

Clicking of the jaw

Pain (joint, ear, side of face)

Difficulty in opening and closing or chewing

15. Habits. Do you:

Clench or grind your teeth while awake or asleep

Bite your lips or cheeks regularly

Hold foreign objects with the teeth (such as pencils, pipe, nails, fingernails)

Mouth breathe while awake or asleep

Dental History

1. Are you having any discomfort at this time?

Yes

2. How frequently do you see your dentist?

6 months

Yearly

Other

If other, please specify frequency

3. Date of last dental visit

MM slash DD slash YYYY

What was done?

4. Are you aware of any lump or swelling in your mouth?

Yes

5. Do you clench or grind your teeth?

Yes

6. Worn a bite plate or other appliance?

Yes

7. Have you ever been given local anaesthetic (freezing)?

Yes

8. Problems of the jaw. Have you experienced:

Clicking of the jaw

Pain joint, ear, side of face?

Difficulty in opening

9. Have you had any serious trouble with any previous dental treatment?

Yes

Please specify

10. Are you tense during dental visits?

Yes

11. Have your teeth shifted, have spaces opened between your teeth, or are they spreading outward?

Yes

12. Do you currently experience? (check any that apply)

Loose teeth

Bleeding gums

Sore gums

Earache

Headache

Neck pain

Clicking in jaw joint

Sensitive teeth

Bad breath

Dry mouth

13. Have you had? (check any that apply)

Orthodontics / Braces

Crowns / Caps or Bridges

Prosthodontics / Periodontics / Gum Treatment

TMJ or Bite Problems

Partial Dentures

Bite Plane / Night Guard

Restorations / Fillings

Endodontics / Root Canal

Oral Surgery

14. How often do you floss your teeth?

Privacy Statement, Insurance, and Signatures

PRIVACY STATEMENT

A. I have read and understand the PRIVACY STATEMENT FOR PATIENTS.

B. I consent to the collection, use, and disclosure of my personal information as presented in the statement.

I, the undersigned, certify that all the above medical and dental information is true to my knowledge and I have not omitted any pertinent information. I understand that it is my responsibility to inform this office of any change in my medical status.

Privacy consent(Required)

I have read and understand the privacy statement and consent to the collection, use, and disclosure of my personal information.

Patient Signature (Guardian’s Signature if patient is under 18)(Required)

Date(Required)

MM slash DD slash YYYY

Dentist Signature

Dental Insurance?

Yes

A. I authorize the release, to my dental benefits plan administrator and the CDA, of information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services to Park Lane Periodontics.

B. I hereby assign my benefits, payable from claims submitted electronically, on my behalf to Park Lane Periodontics.

C. This authorization shall continue in effect until the undersigned revokes it.

Patient Signature (Guardian’s Signature if patient is under 18)(Required)

Date(Required)

MM slash DD slash YYYY

Office Policy

1. Please remember that once you have made an appointment, this time is reserved for you. At least 24 hours prior notice must be given if cancellation is absolutely necessary.

2. Office policy is that services are paid for at each visit by the patient or through direct billing if dental insurance is applicable.

3. Regarding insurance: We will carry out direct billing on behalf of all patients. However, professional services are charged directly to the patient and ultimately patients are responsible for payment of all charges to their accounts.

Medication List / Additional Notes

Park Lane Privacy Statement

Privacy of our patient’s personal information is important to us. We are committed to collecting, using and disclosing personal information responsibly.

Personal Information
Personal information for our purposes is that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes all that information provided by you to us on our patient information/health/medical history form at the first visit and any subsequent visits. Personal information may also include any information provided by you to us during the normal course of communication between patient and dental office staff. We will use and disclose only information provided to us by you or another person acting on your behalf.

Information Protection
We are committed to protecting your personal information. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft and unauthorized access. Access to your personal information shall be on a “need to know” basis.

Information Disclosure
Your personal information shall be disclosed to only those who have a need to know and the specific information disclosed shall be restricted to only that information relevant to the recipients’ need to know. Those who have a need to know include other dentists and health care providers, dental specialists, personal physicians, dental lab. Further, the personal information disclosed to dental benefit providers is limited to only that personal information required by the provider. You may at any time designate any restrictions as to whom we may disclose your personal information or restrict the content of a disclosure.

Information Retention and Destruction
We will retain your personal information for the period necessary to continue providing oral health services to you, and for its related administration. We will destroy information in a secure manner when the information is no longer necessary for the provision of oral health services and is not required to be retained for compliance with Provincial or Federal regulations or statutes.

Your Access to Your Records
We are committed to providing you with open access to your personal information held by us. You may at any time ask us to see your records held by us and to request amendments to that information. We will provide access to you within a reasonable time-frame recognizing your desire for the information and our need to carry on our practice with limited interruption.

Contact
Should you have any questions, comments or concerns, please bring them to the attention of Park Lane Dental Specialists. We will be pleased to assist you.

Patient Intake Form

New Patient Intake Form

Patient Information

Medical History

Dental History

Privacy Statement, Insurance, and Signatures

Office Policy

Medication List / Additional Notes

Park Lane Privacy Statement

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