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#210 - 1077 56 Street, Delta BC, V4L 2A2

info@tsawwassenfamilydental.ca

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Patient Info
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About Us
Services
Patient Info
Contact Us
BOOK APPOINTMENT

Search for:

About Us
Services
Patient Info
Contact Us
Book Appointment

Call Us

+1 604.245.3458

Book Appointment

New Patient Intake Form

Home Patient Info New Patient Intake Form

Welcome to Tsawwassen Family Dental. Please complete the intake form below form prior to your appointment. If you would prefer to fill out a physical form click here to download the PDF.

The following information is required by our office to thoroughly diagnose any condition and give you personal attention. This form is STRICTLY CONFIDENTIAL. Please fill out the form completely.

1Personal Information/ Insurance

2Medical History

3Dental History

Personal Information
Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address City Province Postal Code
Phone*
Email*
Occupation
Employer
Dental Insurance
Do You Have Dental Insurance?*
- Yes
- No
Name of Insurance Plan
I.D. # or Certificate #
Policy Holders Employer
Dental Plan Holders Name
Policy Holders Date of Birth
DD slash MM slash YYYY
Policy or Plan Number
Dependent Number

Medical History
Personal Physician
Prefix First
Specialist
Prefix First
Phone
Address
Do You or Have You Ever Had? (Select All That Apply)
- hospitalization for illness or injury
- to take antibiotics prior to a dental procedure
- heart problems / defect / pacemaker
- heart murmur / ventricular prolapse
- rheumatic fever / scarlet fever
- high blood pressure
- low blood pressure
- a stroke
- artificial prosthesis
- anemia or other blood disorder
- abnormal bleeding
- emphysema
- tuberculosis
- asthma
- breathing or sleep problems
- (snoring, sinus, sleep apnea)
- sinus problems
- kidney disease
- liver disease
- jaundice
- thyroid or parathyroid disease
- hormone deficiency
- high cholesterol
- diabetes
- stomach or duodenal ulcer
- digestive disorders (gastric reflux)
- eating disorders (anorexia/bulimia)
- osteoporosis/osteopenia (taking bisphosphonates)
- arthritis
- glaucoma
- contact lenses
- head or neck injuries
- epilepsy, convulsions (seizures)
- neurologic problems /alzheimers / memory loss
- viral infections and cold sores
- any lumps or swelling in the mouth
- dry mouth
- hives, rash, hay fever
- venereal disease
- hepatitis
- HIV / AIDS
- tumor, abnormal growth
- radiation therapy
- chemotherapy
- emotional problems
- psychiatric treatment
- antidepressant medication
- alcohol/drug dependency
Have You Ever Had an Allergic Reaction to: (Select All That Apply)
- aspirin, ibuprofen, acetaminophen
- penicillin
- erythromycin
- tetracycline
- codeine
- local anesthetic
- fluoride
- metals (gold, stainless steel)
- latex
- any other medications
Name of Medication
Are you: (Select All That Apply)
- presently being treated for any other illness
- aware of a change in your general health
- often exhausted or fatigued
- subject to frequent headaches
- a smoker, smoked previously, use tobacco
- Female – taking birth control pills
- Female – pregnant /nursing
- Male – prostate disorders
Additional Medical Information
List All Medications, Supplements, and/or Vitamins Taken Within the Last Two Years
Reason for Taking
Describe Any Medical Treatment, Impending Surgery, or Other Treatment That May Possibly Affect Your Dental Treatment

Dental History
Referred By
First
Previous Dentist
Prefix First
How Long Have You Been a Patient
Date of Last Dental Exam/ Cleaning
DD slash MM slash YYYY
Date of Last Dental X-Rays
DD slash MM slash YYYY
Date of Last Treatment (eg. fillings, crowns, whitening)
DD slash MM slash YYYY
I Routinely See My Dentist Every (Select One Only)*
- 3 Months
- 4 Months
- 6 Months
- 12 Months
- Not Routinely
How Would You Rate The Condition of Your Mouth (Select One Only)*
- Excellent
- Good
- Fair
- Poor
How Often Do You Brush / Day?*
How Often Do You Floss / Week?*
How Often Do You Brush Tongue / Week?*
What is Your Immediate Dental Concern? (Briefly Describe)*
Dental History Details (Select All That Apply)
Treatment History (Select All That Apply)
- Are you fearful of dental treatment?
- Have you had an unfavorable dental experience?
- Have you ever had complications from past dental treatment?
- Have you ever had trouble getting numb or reactions to local anesthetic?
- Did you ever wear braces, have orthodontic treatment or had your bite adjusted?
- Have you had any teeth removed?
Smile Characteristics (Select All That Apply)
If you are not happy with the appearance and function of your teeth, what would you change?
- Whiter teeth
- Straighter teeth
- Close spaces
- Lengthen teeth
- Contour / reshape teeth
- Replace metal fillings
- Repair chipped / broken teeth
- Replace missing teeth
- Repair worn teeth
- Replace old crowns / caps that don’t match
Gum, Bone, and Tooth Structure (Select All That Apply)
- Are any teeth sensitive to hot, cold, biting, or sweets?
- Have you ever had a toothache, cracked filling, broken, chipped, or cracked tooth?
- Do you feel or notice any holes (ie. Pitting) in your teeth?
- Have you ever been diagnosed or treated for periodontal (gum) disease?
- Have you ever experienced gum recession?
- Is there a history of periodontal disease in your family?
- Do your gums bleed when brushing, flossing, or eating?
- Are your teeth becoming loose?
- Have you ever noticed an unpleasant taste or odor in your mouth?
- Have you experienced a burning sensation in your mouth?
Bite & Jaw (Select All That Apply)
- Do you have any problems chewing gum or hard foods?
- Have your teeth changed in the last 5 years, become shorter, thinner or worn?
- Are your teeth crowding or developing spaces?
- Do you have more than one bite or do you clench (squeeze) your teeth to make them fit together?
- Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
- Do you have tension headaches or sore teeth?
- Do you wear or have you ever worn a bite appliance? (night guard)
Date*
DD slash MM slash YYYY
Signature of Patient (or Parent/ Guardian)*
I hereby certify that the information given here is complete, true and correctly recorded, and I consent to examination and treatment agreed to be necessary or advisable.
CAPTCHA

We provide a warm and welcoming dental care experience for the whole family. Our dental professionals do all types of dental work including cleanings, oral surgery, periodontal care, pediatric dentistry, emergency procedures, cosmetic dentistry, and more. We have a passion for caring and are committed to providing our best patient experience. We want to see you smile!

Reach Us

#210 - 1077 56 Street, Delta, BC, V4L 2A2
+1 604 943 9222
info@tsawwassenfamilydental.ca

Services

Teeth Cleaning and Dental Checkups
Preventative Dental Care
Cosmetic Dentistry
Cavities and Fillings
Root Canal
Prosthodontics
Wisdom Teeth Removal
Dental Implants
Dentures
Invisalign®
Teeth Whitening
TMJ & Jaw Problems
Pediatric Dentistry
Periodontal Gum Care

Hours of Operation

Monday
9:00 AM - 7:00 PM
Tuesday
9:00 AM - 7:00 PM
Wednesday
9:00 AM - 7:00 PM
Thursday
9:00 AM - 5:00 PM
Friday
Closed
Saturday
Select Days
Sunday
Closed

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