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604-428-0880

Metro Scott Oral Care Centre - New Patient Form

Personal Information:

Birthday
Year
Month
Day
Multi-line address

Dental Information:

Do your gums bleed while brushing or flossing?
Yes
No
Have you ever had Orthodontic (braces) Treatments?
Yes
No
Are your teeth sensitive to cold, hot, sweets or pressure?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Have you ever had a head, neck or jaw injury?
Yes
No
Do you have any loose teeth or have they ever shifted?
Yes
No
Does food frequently get caught in your teeth?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Do you have Headaches or Migraines?
Yes
No
Have you had any difficult extractions in the past?
Yes
No
Ever worn a bite plate or other appliance?
Yes
No
Have you ever had difficulty opening or closing jaw?
Yes
No
Have you had any pain in your jaw area?
Yes
No
Have you ever had Periodontal Treatment (gums)?
Yes
No
Do you have any other concerns about having Dental Treatment?
Yes
No
Do you ever feel nervous about visiting the Dentist?
Yes
No
Are you happy with the appearance of your teeth?
Yes
No
Date of last Dental X-Ray:
Year
Month
Day
What can we do to make you smile? Check all that apply, and we'll get back to you with more information about your inquiry:

CHILDREN ONLY

INSURANCE INFORMATION

Relationship

SECONDARY INSURANCE

Relationship
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