Iris Dental Group

Patient's Name

Prefferred Name

Birth date

If Minor, Parent/ Guardian’s Name

Home Phone

Cell Phone

Mailing Address

City

Postal Code

E-Mail

Occupation

Employer

Whom we may thank for referring you to our office

BILLING, CREDIT AND INSURANCE INFORMATION

Covered by Dental Insurance Yes No

If yes, Insurance company

Policy No

ID

Covered by spouse’s Dental Insurance Yes No

If yes, Spouse’s name

Insurance company

Policy No

ID

Spouse’s birth date

Medical Health History

Do you have or have you had any of the following? (Please check any that apply)

Cancer or tumor
Heart ailment or Angina
Heart Murmur, Mitral valve prolapsed or heart defect
Rheumatic fever or Rheumatic Heart disease
Artificial joint or valve
Pacemaker
High or low blood pressure
Tuberculosis or other lung diseases
Kidney disease

Do you smoke or chew Tobacco Yes No

Latex Materials
Penicillin or other antibiotics
Local anesthetics (“Novocain”)
Codeine or other narcotics

Sulfa Drugs
Barbiturates, sedatives or sleeping pills
Aspirin
Any Other

Aspirin
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Insulin, Orinase or other diabetic drugs

Nitroglycerine
Cortisone or other steroids
Osteoporosis (bone density medicines)
Thyroid medicines
Any Other

May be pregnant Expected date of delivery:
Taking hormones or contraceptives

Name of your Physician

Do you have any other disease or condition or problem not listed above

Please add anything else you would like us to know about:

Date:

New Patient Form

IRIS DENTAL GROUP

905-607-7721|2385 Burnhamthorpe Rd W Unit 3, Mississauga, ON L5L 6A4| mississauga@irisdentalgroup.com

Medical Health History

Location

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