Patient Registration

Please fill out the form below, and we'll contact you within the next few days.

Patient Registration and Heath History:
  • All fields with "*" are required
  • Your contact information will only be used for Kitsilano Endodontics

Family Name*
Given Name*
Gender*   Female     Male
Date of Birth* (yyyy-mm-dd)
Address*
City*
Prov*
Postal Code*
Home Phone*
Cell Phone
Email*
Work Phone
Occupation
Employer
Business Address
City
Prov
Postal Code
Emergency Contact
Phone
Family Doctor
Phone
Referring Dentist
Is a Minor   Yes    No
Legal Responsibility

PRIMARY PLAN

Insurance Carrier
Policy or Group No.
ID or Certificate
Div
Subscriber Name
Date of Birth (yyyy-mm-dd)
Employer

SECONDARY PLAN

Insurance Carrier
Policy or Group No.
ID or Certificate
Div
Subscriber Name
Date of Birth (yyyy-mm-dd)
Employer

HEALTH HISTORY

1. Are You feeling pain or discomfort at this time?   Yes    No
2. Have you had a medical examination in the last year?   Yes    No
3. Do you feel very anxious about having dental treatment?   Yes    No
4. Have you been a patient in the hospital during the past two years?   Yes    No
5. Please list all medications you are on now.
6. Are you allergic or have you reacted to any of the following medications?

7. Are you aware of being allergic to any other medication or substance?   No    Yes
If yes, please specify?
8. Select all the following which you have/had?

9. Do you wish to speak privately to the Doctor about any medical condition?   Yes    No
10. Do you ever wake up from sleep short of breath?   Yes    No
11. Do you have a tendency to faint?  Yes    No
12. Do you have frequent severe headaches?  Yes    No
13.Have you had regular dental examinations (annuall) in the past?   Yes    No
14. If you have any disease, condition, or problem not mentioned above please list?
15. Are you pregnant? (Female Patients Only)   Yes    No