PATIENT REGISTRATION

Date

Patient’s Information

First Name

Middle Initial

Last Name

Gender

Female

Male

Birth Year

Birth Month

Birth Day

Home Phone

Cell Phone

Email Address

Home Address

City

Province

Postal Code

MSP Care Card

Family Dr Name

Contact Number

Emergency Contact/Guardian Information (if patient is under 18)

Emergency Contact: First Name

Emergency Contact: Last Name

Date of Birth

Relationship to Patient

Home Phone

Cell Phone

Please Provide Us With Your Dental Insurance Information for Your Reimbursement

Primary Carrier

Name of Insured

Relationship to Patient

Date of Birth

Policy Number

ID #

Employer

Address if different than patient's

Secondary Carrier

Name of Insured

Relationship to Patient

Date of Birth

Policy Number

ID #

Employer

Address if different than patient's

I,______ confirm the above information is true and correct in all respects.I also understand that payment in full is required for all treatment rendered at APEX Surgical Centre for Oral & Facial Surgery at the time of service.APEX Surgical will submit your claim to your insurance company for your reimbursement or provide a completed Dental Claim Form with all the specifications required by insurance companies to process your claim.

Credit Card Number

Expiration Date

Credit Card Type

MasterCard®

Visa®

PATIENT MEDICAL HISTORY

Patient's Name

Birth Day

Birth Month

Birth Year

Has there been any changes in your health within the past year?

Yes

Are you now under the care of a physician?

Yes

1. What are you being treated for?

Other

Are you presently taking or have you recently taken any of the following? Check if YES

Anticoagulants or Blood Thinner Pills

Antidepressants

Antibiotics

Asprin/ASA

Blood Pressure Pills

Heart Pills

Insulin

Steroids/Cortisone

Other

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

Current medications (please list all prescription and non-prescription medications—ask your pharmacy for a print if unsure)

Medication Name 1

Dose

Medication Name 2

Dose

Medication Name 3

Dose

If you take more than listed, please check this box and ensure you provided your pharmacy information.

I have provided that information

Are you currently taking any suppliments, specifically ginko, garlic, or ginseng?

Yes

If yes, which one

Have you ever had an allergic reaction to any drugs/medications or foods, specifically nuts or eggs?

Yes

If yes, which one

Have you ever had any serious illnesses, operations, or hospitalizations that as yet have not been mentioned?

Yes

Have you ever had a general anaesthetic (put to sleep?) for a procedure?

Yes

If yes, were there any problems or a family history of this problem?

Height

Weight

Do you have any other medical conditions that are not listed on this form?

Yes

If yes, what is the medical condition?

Do you drink alcohol?

Yes

Rarely

Socially

Daily

Do you use cannabis products?

Yes

How many years have you been smoking or using cannabis products?

Amount

Do you smoke?

Yes

For how many years have you been smoking

Amount

Are you pregnant, or is there a chance you may be?

Yes

Are you Nursing

Yes

Are you currently on birth control?

Yes

Name of Patient, Parent, or Guardian Signing the form