Adult Patient Information Form

Adult Patient Information
Last
First

Medical History

Have you ever had any serious illnesses or operations?
Are you presently under any medical treatment?
Are you taking any medications at present or recently?
Have you taken any Steroids or Cortisone in the last three years?
Do you suffer from any allergies?
Have you ever been told that you need antibiotics before dental treatment?
Have you ever had any of the following (please check where applicable)

Dental History

Do your gums bleed when brushing?
Do you suffer from pain or swelling of your gums?
Does food catch between your teeth?
Do you clench or grind your teeth?
Is there anything about the appearance of your teeth that bothers you?
Do you experience any of the following JAW problems? (please check where applicable)
There is a $75.00 charge for appointments that are cancelled with less than 48 HOURS NOTICE (2 Full Business Days)
Archibald Dental Centre is happy to help you receive your maximum dental benefit provided under your insurance plan. The amount of coverage you receive is dependent on the agreement between your employer and the insurance company. However, there are many different plans available and we cannot be experts on all of them. As a patient, I understand that I am financially responsible for the entire treatment or any portion not covered by insurance and that payment is due on the date of service.