429 Thorold Rd, Welland, ON L3C 3W4
(289) 273-7242
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Patient Registration Form

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Welcome to Our Office

We want your dental visits to be comfortable, safe, and personalized to you. Your health history helps our dental team understand your needs and provide care that is appropriate for you.

Please answer the questions as completely as possible. If you are unsure about an answer, simply let us know and we can review it with you.

All information provided is kept private and is used to help us provide safe and appropriate dental care.

Patient Registration
Contact Information
What is the best way for us to communicate with you?
In case of Emergency Contact:
Insurance information: Primary
Secondary
Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?
Has there been any change in your general health in the past year?
Are you taking any prescription, non-prescription medications, or herbal supplements?
Do you have any allergies?
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have any conditions which may affect your immune system (i.e leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Do you have, or have ever had any of the following? (Please select any that apply to you)
Are there any conditions/diseases not listed that you have or have had?
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?
For women only:
Are you pregnant?
Are you breastfeeding
Lifestyle & Habits

These questions help us understand factors that may affect your oral and overall health.

Do you currently smoke or use tobacco products?
Do you currently use vaping products?
Do you use cannabis or recreational substances?
How often do you consume alcoholic beverages?
Do you frequently consume sugary drinks, energy drinks, sports drinks, or other acidic beverages?
How often do you snack between meals?
Dental History
What Brings You In Today?
What is the main reason for your visit today?
Are you experiencing any pain or discomfort today?
How would you describe it?
How much discomfort are you experiencing? (0 = No pain, 10 = Severe pain)
Have you ever had a bad experience at the dentist?
Do you feel nervous or anxious about dental treatment?
Is there anything that helps you feel more comfortable during dental treatment?
Would you like us to discuss your level of comfort before beginning treatment?
Your Dental Health
Have you ever had:
Would you like our staff to provide you with a release form to have your previous office forward xrays and treatment record?
How often do you see the dentist?
Signature
Patient signature *