Welcome to Prairie Smiles Dental Group patient form is exclusively for existing patients ONLY IF YOU ARE A NEW PATIENT, PLEASE CONTACT US TO BOOK YOUR FIRST APPOINTMENT Phone (306) 783 - 3233 Fax (306) 782 - 7003 prairiesmiles@sasktel.net Name * First Name Last Name Gender * Male Female Other Preferred Pronouns * They/Them She/Her He/Him Other Home Phone Number (###) ### #### Cellphone number * (###) ### #### Email * Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country SK Health Number * Date of Birth * MM DD YYYY Marital Status * Single Married Widowed Divorced Other Do you have a Treaty number? * Yes No Spouse / Parent / Guardian Name * Contact Number * (###) ### #### Do you have dental insurance? * Yes No Pharmacy * 1) General Health * Excellent Good Fair Poor 2) Name of your Physician * 3) Are you taking any medications at this time? * Yes No List all medications and the reason for taking it 5) Have your ever been treated for any of the following. Please indicate which one(s) * ADHD Diabetes Epilepsy Heart Disease Heart Murmur Radiation Congenital Heart Disease High Blood Pressure HIV AIDS Anxiety Depression Hepatitis A B C Stroke Thyroid Disorder Tuberculosis Ulcers Rheumatic Fever STI Hay Fever Arthritis Bipolar Schizophrenia Other 4) Have you ever had any adverse effect to any of the following ADHD Diabetes Epilepsy Heart Disease Heart Murmur Radiation Congenital Heart Disease High Blood Pressure HIV AIDS Anxiety Depression Hepatatis A B C Stroke Thyroid Disorder Tuberculosis Ulcers STI Hay Fever Arthritis Bipolar Schizophrenia Other 6) Do you have or have you ever had asthma? * Yes No 7) Do you have or have you ever had any heart or blood pressure problems? * Yes No 8) Are you being treated for osteoporosis? Yes No A. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? Yes No B. If yes, do you require a PRE MEDICATION before dental treatment? Yes No 10) Are you prone to fainting? Yes No 11) Have you been diagnosed with Sleep Apnea? Yes No If yes, do you use CPAP? Yes No 12) A. Have you ever had cancer? Yes No B. If yes, specify the following 13) Do you have a bleeding problem or bleeding disorder? Yes No 14) A. Do you have a prosthetic or artificial joint? Yes No B. If yes, date of surgery? Complications after surgery? Yes No 15) Do you have any conditions or therapies that could affect your immune system? * 16) Have you ever had hepatitis, jaundice, or liver disease? Yes No 17) Have you ever been hospitalized for any illness or operations? If yes, please explain. 18) Do you have any disease, condition or problem not listed above? * 19) Women, Are you pregnant? Yes No How many weeks are you? Dental Health 1) Have you ever had any injury to the face or jaw? * 2) Do you clench, gnash or grind your teeth? * 3) Do you have any problems chewing? * 4) Do your gums bleed when Brushing Flossing Spontaneously PATIENT CERTIFICATION AND CONSENT I, the undersigned, certify that all of the above information is true to my knowledge and I have not omitted any pertinent information. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable including the use of local anaesthetic as indicated. I will assume responsibility for fees associated with these procedures. I understand I must provide 48 hours notice to cancel appointments, or a charge will be applied. OFFICE POLICY FOR SERVICES RENDERED Payments are expected when services are rendered. We accept MasterCard, Visa, Debit, E-transfer and Cash. Patient (Parent / Guardian) Signature / Name * Provider Signature / Name * Thank you! We will contact you as soon as possible to book your first appointment with us! Your answers are important to insure proper treatment. All information is confidential. Call us now • (306) 783 3233 • Call us now • (306) 783 3233 • Call us now • (306) 783 3233 • Our contact info Broadway Location 130-41 Broadway Street West Yorkton SK S3N 0L6 Canada Phone +1 (306) 783 - 3233 Email prairiesmiles@sasktel.net Hours of operation Monday - Thursday: 8:00 am - 5:00 pmFriday: 7:00 am - 2:00 pmSaturday & Sunday: Closed
