Patient Registration Form

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

Patient Registration - Please Note All Fields Are Required To Be Completed (Put NA for any fields rather than blank where required).

Date

Patient Full Name *

Date Of Birth *

Address (Full Residential Address | Including Post Code) *

Please include city and post code.

Phone Numbers: *

Please provide all numbers that are available - Home, Work, Cell. As well as Spouse Cell + Work.

Email *

I consent to be contacted by Email if I have provided my Email address to the office.

Work Place Company *

Name + Phone Number

Work Address

In case of Emergency: *

(Name + Relationship + Phone Number)

Dental Insurance

Do you have Dental Insurance? *

Person Responsible for account: *

Name + Phone Number

Name of insurance company: *

Policy holder: *

Policy holder date of birth: *

Please let the front desk know if you have more than one insurance.

Group/Policy #: *

Certificate Number / ID #: *

Dental Insurance (Secondary Insurance If Applicable)

Secondary Insurance - Name of insurance company:

Secondary Insurance - Policy holder:

Secondary Insurance -Policy holder date of birth:

Please let the front desk know if you have more than one insurance.

Secondary Insurance - Group/Policy #:

Secondary Insurance - Certificate Number / ID #:

Dental History

When was your last dental visit? *

Name of previous dentist: *

When did you last have dental x-rays? *

How often do you brush your teeth? *

How often do you floss your teeth? *

Have you been seeing a dentist regularly? *

Yes
Maybe
No

Have you ever been advised to take antibiotics before dental appointments? *

Yes
Maybe
No

Do you have any pain when you chew? *

Yes
Maybe
No

Have you ever been in a vehicle accident or experienced any pain in your jaw joints? *

Yes
Maybe
No

If you answered yes to the last question, who performed the surgery and when was it done? *

Have you had any surgeries in the last six months? *

Do any of your teeth ache? *

Yes
Maybe
No

Do your gums bleed when you brush? *

Yes
Maybe
No

Do you feel that you have bad breath? *

Yes
Maybe
No

Have you ever had any implant surgery in one or both of your jaws or jaw joints? *

Yes
Maybe
No

Are you being followed by a dental specialist? *

Please list anything else not mentioned above regarding your past dental history. *

Medical History

Date of last medical examination: *

Name of family physician: *

Is your physician treating you now? *

If you answered yes please specify. *

Are you being treated by a medical specialist? *

If you answered yes please specify. *

. Are you on medication or herbal remedies or supplements? *

If you answered yes please specify. *

Do you have any allergies? *

If you answered yes please specify. *

Are you pregnant? *

If you answered yes please specify how many months? *

Do you smoke? *

Is there any other medical condition we should be made aware of? *

Have you ever had or been treated for? *

Respiratory Disease
Rheumatic Fever
Third Choice
Scarlet Fever
Shortness of Breath
Thyroid Disease
Kidney Disease
Psychiatric Disease
Mitral Valve Prolapse
High Blood Pressure
Low Blood Pressure
Bleeding Disorder
Arthritis
Blood Disorders
Venereal Disease
Artificial Joints
Anemia
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis A
Diabetes
Sinus
Pacemaker
Cancer
Herpes
Stroke
Gastric Ulcer
Dizzy Spells
Asthma
Heart Murmur
Disease of Eyes Nose Or Throat
Tuberculosis
Liver Disease
Heart Disease
Aids or HIV Positive
Chest Pain
Environmental Allergies
None Of The Above

I, the undersigned, certify that I have provided and accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that 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 service for myself and my dependants is mine and I assume responsibility for fees associated with these services. *

Full Name *

Date *

Website

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

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Contact Us

102-1500 Bank street Ottawa, Ontario K1H 7Z2

613-706-4101

Info@blueherondentalgroup.ca

Clinic Hours

Mon: 7:30am - 3:30pm
Tue: 7:30am - 3:30pm
Wed: 7:30am - 3:30pm
Thu: 7:30am - 7:30pm
Fri: 7:30am - 3:00pm

Sat: Closed
Sun: Closed