Doon Village Dental Form
New Patient Registration Form
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First Name *
Last Name *
Gender *
Date Of Birth
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Home Phone
Cell Phone *
Email
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Home Address
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Emergency Contact
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Emergency Contact Phone Number
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Relationship to Patient
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How did you hear about us?
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All information collected is considered confidential and managed in compliance with the personal health
information protection act.
Do we have the permission to contact you by phone or email?
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Insurance Details
If applicable
Do you have insurance? 
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Name Of Insurance Provider
Policy Holders First & Last name
Policy Holders Date of Birth
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Policy/Group Number
Certificate/Member ID Number
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 fill in the entire form.
Are you being treated for any medical condition at the present or have you been treated in the past year?
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If yes, please explain:
When was your last medical checkup?
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Has there been any changes in your general health in the past year?
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If yes, please explain:
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? 
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If yes, please explain:
Do you wear any medical patches? *
Do you have any allergies?
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Have you ever had a peculiar or adverse reaction to any medication or injections?
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If yes, please explain:
Do you have or have you ever had asthma?
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Do you have or have you ever had any heart or blood pressure problems? 
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If yes, please explain:
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
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Do you have a prosthetic or artificial joint? 
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Do you have any conditions or therapies that could affect your immune system? (i.e. leukemia, AIDS, HIV infection, radiotherapy/chemotherapy)
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Have you ever had hepatitis, jaundice or liver disease? 
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Do you have a bleeding problem or bleeding disorder? 
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Have you ever been hospitalized for any illnesses or operations?
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If Yes, please explain:
Do you have or every had any of the following? Please check all that applies.
Are there any diseases or medical conditions that run in your family? 
Do you smoke or chew tobacco?
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Are you nervous during dental treatments?
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Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
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Are you currently breastfeeding? 
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Are you currently taking birth control?
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Dental History
Please answer to the best of your knowledge. 
When was your last dental visit?
When did you last have dental x-rays?
How often do you brush your teeth?
How often do you floss?
Have you been seeing a dentist regularly? 
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Do any of your teeth ache?
Have you ever been advised to take antibiotics before dental appointments?
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Do your gums bleed when you brush?
Do you have pain when you chew?
Do you feel you have bad breath?
Have you ever been in a vehicle accident or experienced a blow to your jaw? 
Have you ever had any implant surgery in one or both of your jaw joints?
Please list anything else not mentioned above regarding your past dental history
Doon Village Dental Terms and Conditions
OFFICE INSURANCE POLICY: You are responsible for knowing your insurance coverage. We are not familiar with your specific plan coverage so it’s important to know how your plan works. Always read the information booklet or other materials available from your benefits provider.
You should also be aware of your co-payment and deductibles. Co-payment — also called co-insurance — is the part of the bill you won’t be reimbursed for. Many dental plans have a percentage of the claim amount (typically 20 to 50 per cent) that is not covered by the dental plan. If your dental plan only covers part of the cost of your treatment plan, you’ll need to cover the rest.
If you have concerns as to whether or not a procedure will be covered under your benefits, kindly ask us to submit a pre-authorization to your plan. We may receive an immediate response but it normally takes between 2-6 weeks to receive a response. Keep it mind that majority of insurance plans will only send their response to the policy holder.
Remember: it is a courtesy of your dental provider to accept assignment of benefits from your insurance
company. Although we may try to the best of our abilities, it is unrealistic to expect the dental provider to know
your insurance coverage, frequency limitations or benefit maximums you may have.

MISSED APPOINTMENT/ LATE CANCELLATIONS: Please note that we require a minimum of 48 hours notice to change or cancel an appointment. The fee for short notice cancellation or missed appointments will result in a $50.00 charge to your account. This payment must be taken care of in order to reschedule an appointment at our clinic in the future.  
I agree to the terms & conditions
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Required
By signing below, you agree that you have reviewed the above terms and conditions set out by Doon Village Dental.

By signing below, you agree that you are given an accurate and complete personal, medical, and dental history form and have not omitted any information.
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Patient signature *
Today's Date *
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Dentist signature
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