Welcome!

PATIENT INFORMATION 1
GETTING TO KNOW YOU
NAME

I PREFER TO BE CALLED

DR. MR. MRS. MS. MISS OTHER:

ADDRESS

CITY /PROVINCE POSTAL

CODE
PHONE (HOME)

(WORK)

(CELL)

EMAIL ADDRESS

DATE OF BIRTH AGE

WHO MAY WE THANK

FOR REFERRING YOU?

ACCOUNT INFORMATION 2
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
NAME

RELATIONSHIP TO PATIENT

ADDRESS

CITY/PROVINCE POSTAL
CODE
PHONE NUMBERS

YOU
EMPLOYER

OCCUPATION

WORK ADDRESS

CITY/PROVINCE POSTAL
CODE

YOUR SPOUSE/PARTNER
NAME

EMPLOYER OCCUPATION

WORK ADDRESS

CITY/PROVINCE POSTAL
CODE
PHONE (WORK)
 Dr. Allan Finkleman*
Dr. Alex Zimmer*
*Services provided by dental corporation

DENTAL INSURANCE 3
PRIMARY CARRIER
INSURANCE
COMPANY
EMPLOYEE

GROUP #

EMPLOYEE #/ID #

DATE OF BIRTH

MAXIMUM DEDUCTIBLE

% BASIC % MAJOR

SECONDARY CARRIER
INSURANCE
COMPANY
EMPLOYEE

GROUP #

EMPLOYEE #/ID #

DATE OF BIRTH

MAXIMUM DEDUCTIBLE

% BASIC % MAJOR

METHOD OF PAYMENT
CASH CHEQUE

CREDIT CARD DEBIT CARD

4
We require 48 hours notice to reschedule
appointments; we charge a fee for broken
appointments without sufficient notification.

Payment is due on the day of treatment.

Interest will be charged on overdue accounts
at 1.5% per month, or 18% per annum.

I, the undersigned, understand that it is

my responsibility to pay for dental treatment
for both myself and for my dependents. I
assume all responsibility for fees associated
with my/our dental treatment.

SIGNATURE:

DATE
DR. ALLAN FINKLEMAN DR. ALEX Z

HEALTH QUESTIONNAIRE
PATIENT'S NAME MEDICAL
DOCTOR'S NAME
DATE OF BIRTH AGE MEDICAL
DOCTOR'S PHONE #
PHARMACY, DATE OF LAST BLOOD
IF APPLICABLE MEDICAL VISIT PRESSURE

DO YOU HAVE, or HAVE YOU EVER HAD, any of THE FOLLOWING CONDITIONS?
ACID REFLUX DISEASE DIABETES HIGH CHOLESTEROL MALIGNANT HYPERTHE

AIDS/HIV INFECTION DRUG/ALCOHOL DEPENDENCY HIGH/LOW BLOOD PRESSURE MENTAL HEALTH PROB

ALZHEIMER'S DISEASE EPILEPSY/SEIZURES IMMUNE DISORDERS NECK/BACK PROBLEMS

ANGINA/CHEST PAIN FAINTING INFECTIVE ENDOCARDITIS NEUROLOGICAL DISOR

ANOREXIA/BULIMIA GASTRO-INTESTINAL DISEASE INJURY TO FACE/JAW ORGAN TRANSPLANT

ARTHRITIS HEART ATTACK JOINT REPLACEMENT RADIATION/CHEMOTHE

ASTHMA HEART MURMUR KIDNEY DISEASE STROKE

BLOOD DISORDERS HEART PACEMAKER LIVER DISEASE/JAUNDICE THYROID PROBLEMS

CANCER/TUMOURS HEART VALVE CONDITION LOSS OF EYESIGHT TUBERCULOSIS

COLD SORES/CANKERS HEART -- OTHER LOSS OF HEARING VENEREAL DISEASE

CONGENITAL HEART DISEASE HEPATITIS LUNG DISEASE NONE OF THE ABOVE**

OTHER ILLNESSES (OR SURGERIES) -- PLEASE EXPLAIN: CONCERNS WITH DENTAL TREATMENT -- PLEASE EXPLAIN:

Please list all MEDICATIONS taken (Including over-the-counter drugs, vitamins, and herbal supplements, etc.
1 PURPOSE OF DRUG

2 PURPOSE OF DRUG

3 PURPOSE OF DRUG

4 PURPOSE OF DRUG

5 PURPOSE OF DRUG

INR LEVEL STAFF NOTES: PROPHYLA

REQUIRED ANTIBIOT
(2.0 - 3.0) REQUIR

Have you had any ADVERSE EFFECTS or ALLERGIC REACTIONS to any of the following?

CODEINE PENICILLIN LOCAL ANESTHETICS LATEX METAL

OTHER ALLERGY -- PLEASE EXPLAIN: NO KNOWN ALLERGI

SMOKING STATUS GENERAL RELEASE

NON-SMOKER To be best of my knowledge, the questions on this form have been

accurately and completely answered. I will not hold my dentist or
PAST SMOKER members of his staff responsible for any errors or omissions that I
FROM ___________ TO ____________
have made in the completion of this form. I acknowledge that it is
responsibility to inform my dental office of any changes in my hea
SMOKER SINCE ___________ . #/DAY ____________ status and/or medications.

WOMEN ONLY -- ARE YOU PREGNANT? SIGNATURE OF

PATIENT (OR GUARDIAN)
DATE STAFF
YES -- DUE DATE: NO
INITIALS
 DR. ALEX ZIMMER

QUESTIONNAIRE

BLOOD
PRESSURE

R HAD, any of THE FOLLOWING CONDITIONS?

MALIGNANT HYPERTHERMIA

MENTAL HEALTH PROBLEMS

NECK/BACK PROBLEMS

NEUROLOGICAL DISORDERS

ORGAN TRANSPLANT

RADIATION/CHEMOTHERAPY

STROKE

THYROID PROBLEMS

TUBERCULOSIS

VENEREAL DISEASE

NONE OF THE ABOVE***

CONCERNS WITH DENTAL TREATMENT -- PLEASE EXPLAIN:

r-the-counter drugs, vitamins, and herbal supplements, etc.)

PURPOSE OF DRUG

PURPOSE OF DRUG

PURPOSE OF DRUG

PURPOSE OF DRUG

PURPOSE OF DRUG

PROPHYLACTIC
ANTIBIOTICS
REQUIRED

or ALLERGIC REACTIONS to any of the following?

ANESTHETICS LATEX METAL

NO KNOWN ALLERGIES

GENERAL RELEASE
To be best of my knowledge, the questions on this form have been
accurately and completely answered. I will not hold my dentist or any
members of his staff responsible for any errors or omissions that I may
have made in the completion of this form. I acknowledge that it is my
responsibility to inform my dental office of any changes in my health
status and/or medications.

STAFF
INITIALS