New user registration - Atlantic Oral Dental Surgery

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Patient Services
Referring Dentists
- More Links
  - Contact Us
  - All Services
- Resources
  - Referral Form

Get In Touch

Confidential Medical History

Confidential Patient Information

Download PDF Form

Patient Name(Required)

First Middle Last

Age

Please enter a number from 0 to 150.

Date of Birth(Required)

MM slash DD slash YYYY

Email

Weight(lb)

Height(in)

What is your pronouns

She/Her

He/Him

They/Them

I prefer not to say

Gender

Male

Female

Non-binary

Transgender

Address

Street Address Address Line 2 City State / Province / Region Postal Code Country

Home Phone

Work Phone

Cell Phone(Required)

Emergency Contact

Phone

Medical Doctor

Phone

Pharmacy

Phone

MCP Number

Expiration Date(Required)

MM slash DD slash YYYY

Have you had a heart attack, chest pain, angina, or chest tightness?

Yes

No

Have you ever had heart failure or fluid in your lungs?

Yes

No

Do you have a heart murmur or valve problem?

Yes

No

Have you ever been treated for an irregular heartbeat?

Yes

No

Do you have high blood pressure?

Yes

No

Do you have asthma?

Yes

No

Do you cough frequently or have bronchitis or emphysema?

Yes

No

Does climbing one flight of stairs or walking one city block make you short of breath?

Yes

No

Do you now or have you recently smoked cigarettes?

Yes

No

Packs per day

Years smoked

Do you have liver disease or a history of jaundice or hepatitis?

Yes

No

Do you have sleep apnea?

Yes

No

Do you drink more than three drinks of alcohol per day?

Yes

No

How many per week?

Do you have indigestion, heartburn, or hiatal hernia?

Yes

No

Do you have a history of thyroid problems?

Yes

No

Do you have diabetes?

Yes

No

Diabetes is

Diet-controlled

On pills

On insulin

Do you have a kidney problem?

Yes

No

Do you have numbness or weakness of your arms or legs?

Yes

No

Have you had epilepsy, blackouts, seizures, or a stroke?

Yes

No

Have you had problems with blood clots or excessive bleeding?

Yes

No

Do you have any other medical conditions?

Yes

No

Please list

Have you ever had a general anaesthetic?

Yes

No

When was your last?

MM slash DD slash YYYY

Has your health changed since your last anesthetic?

Yes

No

Have you or any of your family had a reaction to an anesthetic or the placement of a breathing tube?

Yes

No

Do you have neck or jaw pain or arthritis?

Yes

No

Is there a possibility that you are pregnant?

Yes

No

Have you ever taken Ozempic or Ozempic like medications, either currently or in the past?

Yes

No

Have you taken prednisone, steroid medication or cortisone-like drug in the past year?

Yes

No

Would you refuse a blood transfusion as a life-saving procedure?

Yes

No

ALLERGIES (Please list any food or medication allergies that you have)

MEDICATIONS – Please list any medications (including herbal supplements) you are taking (name, dosage, how often):

Please use commas as you list the medications

OPERATIONS – Please list any operations you have had in the past:

FOR TELEDENTISTRY CONSULATIONS ONLY – Please check the box and provide signature below(Required)

I hereby consent to and authorize Atlantic Oral Surgery & and Dental Implant Centre to use teledentistry for consultations with video and or/ audio recording.

Patient Signature(Required)

Date(Required)

MM slash DD slash YYYY

REVIEWED BY

Date

MM slash DD slash YYYY

Atlantic Oral Surgery & Dental Implant Centre is a multidisciplinary centre offering high-quality oral and maxillofacial surgery, orofacial pain, oral pathology and oral radiology services to patients living in or near St. John’s, NL. Our specialty team is dedicated to patient care, comfort and the latest treatment options including experts in oral surgery, oral medicine and oral pathology.

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