New Patient Form

Mclean Teeth Dental Hygiene Care

Home
About
Services
Contact
FAQ
Dental Boutique
- Mclean Teeth Products
- Whitening Products

NEW PATIENT FORM

Dear New Patient,

We want to take this time to welcome you to Mclean Teeth Dental Hygiene Care! Thank you for choosing us to be part of your dental hygiene care journey :)

Your time is valuable to us, so to make your first visit quick and easy, kindly complete this form at your own convenience before your appointment.

If you would like to complete this form at our office, you are more than welcome to! Please ask for assistance with any questions or concerns you may have by sending us an email or giving us a call anytime!

Thanks, and we're looking forward to meeting you soon!

Sincerly,

The Mclean Teeth Team

REFERRAL INFORMATION

How Did You Hear About Mclean Teeth? *

Social Media Lives in Area Works in Area Friend or Family Patient Referral Employee Referral Event Search Engine Other

Check all that applies to you

If other, please specify *

PATIENT CONTACT INFORMATION

* Indicates required field

Title *

Mr. Mrs. Ms. Mst. Miss. Dr.

Please choose one

Name *

First

Last

Date of Birth *

Year/ Month/ Day

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Email *

Preferred Method of Contact *

Email Address Home Phone Number Cell Phone Number Work Phone Number

Check all that applies to you

Occupation *

Name of guardian/parents (if under 18 or under guardianship) *

In case of emergency who should we contact?

Emergency Contact Name *

Relationship *

Emergency Contact Phone Number *

Name of Family Doctor *

Family Physician *

Province and City Name *

Family Doctor Phone Number *

Specialist Name *

Specialist Phone Number *

Pharmacy Name/ or Number *

INSURANCE REGISTRATION

Do you have dental insurance? *

Yes No

Please choose one. You may skip this part of the form if you DO NOT have dental insurance.

If you have answered "yes", please complete the following information. If you do not have dental insurance, please skip this part of the form.

PRIMARY INSURANCE

Insurance Policy Holder *

Self Spouse Parent/Guardian Other

Please choose one

Insurance Company Name *

Subscriber's Employer *

Name of Insurance Policy Holder *

Policy Holder Date of Birth *

Day/Month/Year

Group Policy/Plan Number *

ID/Certificate Number *

SECONDARY INSURANCE

Insurance Policy Holder *

Self Spouse Parent/Guardian Other

Please choose one

Insurance Company Name *

Subscriber's Employer *

Name of Insurance Policy Holder *

Group Policy/Plan Number *

ID/Certificate Number *

Policy Holder Date of Birth *

MEDICAL HISTORY

The following information is required to enable us to provide you with the best possible dental hygiene care. All information is strictly private and is protected by dental hygienist-patient confidentiality. The dental hygienist will review the questions and explain any that you do not understand. Please fill in the entire form.

Are you currently being treated for any medical condition or have you been treated within the past year *

Yes No Maybe/ Not sure

Please choose one

When was your last medical checkup? *

Day/Month/Year (Please Provide a Rough Estimate if Uncertain)

Has there been any change in your general health in the past year? *

Yes No Maybe/ Not sure

Please choose one

Do you have any allergies *

Yes No Maybe/ Not sure

Please choose one

If so, what are they? *

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

Yes No Maybe/ Not sure

Please choose one

Have you ever had a peculiar or adverse reaction to any medicines or injections *

Yes No Maybe/ Not sure

Please choose one

If so, what are they? *

Do you have or have you ever had any heart or blood pressure problems? *

Yes No Maybe/ Not sure

Please choose one

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

Please choose one

Do you have a prosthetic or artificial joint? (i.e. knee or hip?) *

Yes No

Please choose one

Do you have or have you ever had any of the following? *

chest pain, angina rheumatic fever pacemaker steroid therapy heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) None of these apply to me

Please check all that applies to you.

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *

Yes No Maybe/ Not sure

Please choose one

Are there any conditions or diseases not listed above that you have or have had *

Yes No

Please choose one

If so, please specify what they are *

Do you smoke or use other nicotine products? *

Yes No

Please choose one

Are there any diseases that run in the family? (e.g. diabetes, cancer, heart disease) *

Yes No Maybe/ Not sure

Please choose one

For Women Only:

Are you pregnant? *

Yes No

Please choose one

If so, what is your expected delivery date? *

Are you breast feeding? *

Yes No

Please choose one

Do you take birth control pills *

Yes No

Please choose one

DENTAL HISTORY

Date of Your Last Dental Visit? *

Please Provide a Rough Estimate if Uncertain

Date of Your Last Dental Cleaning? *

Please Provide a Rough Estimate if Uncertain

Who was Your Previous Dentist? *

Date of Your Last Dental X-rays *

Please Provide a Rough Estimate if Uncertain

How Would You Describe Your Teeth? *

Good Fair Poor

Please Check Any of the Following Problems that May: Apply to You *

Sensitivity (hot, cold, and/or sweet) Tooth Pain Headaches, earaches, or neck pain Jaw joint pain (clicking/cracking) Grinding or clenching teeth Bleeding swollen or irritated gums Loose, chipped, or shifting teeth Bad breath or bad taste in your mouth None of these apply to me

Check all that applies to you

Are you dissatisfied with the appearance of your teeth *

Yes No Maybe/ not sure

Any teeth extracted due to accident, decay, or gum disease? *

Yes No Maybe/ Not sure

If yes, please explain *

Have you ever had any complications after extractions? *

Yes No Maybe/ Not sure

Are you anxious during dental visits? *

Yes No Maybe/ Not sure

Do you think you might like to have your dental treatment done with sedation? *

Yes No Maybe/ Not sure

Do you use any of the following as part of your oral hygiene regiment? *

electric toothbrush waterpic floss fluoride rinse/tablet softpics fluoridated toothpaste proxybrush natural toothpaste stimudent flosswand prevident toothpaste toothpic rubbertip

Other(s) *

GENERAL RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dental hygienist shall be governed and construed in accordance with the laws of the province of Ontario.

Click here to read the consent form!

Do you agree to the patient certification and consent? *

I agree I do not agree

Please choose one

Signature (Place your full name below) *

Submit

ALL DONE!

McLean Teeth

Dental Hygiene Care

f ig in

Explore

Home About Services FAQ Dental Boutique Contact

Contact

Phone: (437) 246-8331

Email: [email protected]

Book In-Office:
Book a Studio Visit →

Book Mobile Visit:
Request Mobile Care →

Hours of Operation

Monday: 10 a.m.–6 p.m.

Tuesday: 10 a.m.–6 p.m.

Wednesday: 10 a.m.–6 p.m.

Thursday: 10 a.m.–6 p.m.

Friday: 9 a.m.–3 p.m.

Saturday: 9 a.m.–3 p.m.

Sunday: Closed

HOME ABOUT SERVICES FAQ NEWS CONTACT FORMS

Home
About
Services
Contact
FAQ
Dental Boutique
- Mclean Teeth Products
- Whitening Products

NEW PATIENT FORM

REFERRAL ​INFORMATION

PATIENT CONTACT INFORMATION

In case of emergency who should we contact?

INSURANCE ​REGISTRATION

PRIMARY INSURANCE

SECONDARY INSURANCE

MEDICAL HISTORY

For Women Only:

DENTAL HISTORY

GENERAL RELEASE

Click here to read the consent form!

ALL DONE!

HOME ABOUT SERVICES FAQ NEWS CONTACT ​​FORMS

REFERRAL INFORMATION

INSURANCE REGISTRATION

HOME ABOUT SERVICES FAQ NEWS CONTACT FORMS