WELCOME TO DR. SAM WINTER'S OFFICE

Thank you for filling out this form before coming for your first appointment. Please note that all information you provide is completely condfidential.

Mr Mrs Ms Dr First name
Last name
Birth: day month year
Home address
City
Postal code
Home phone
Cell phone
Email

Employer
Employment address
Work phone and extension
Occupation


Referred by
Spouse
PRIMARY DENTAL INSURANCE CARRIER SECONDARY INSURANCE CARRIER
Insurance company
Name of insured
Insurance company
Name of insured
Social Insurance Number
Employer
Social Insurance Number
Employer
Group Number
Certificate #
Limits
Deductible
 Group Number
Certificate #
Limits
Deductible
Coverage percent: A.   B.   C.   Coverage percent: A.   B.   C. 
NOTE: I understand that any portion of fees not paid by insurance will be my responsibility.

Patient signature _______________________________ (sign in office) Date: __________________________________

HEALTH QUESTIONNAIRE To help insure your well-being while receiving treatment in our office, please answer the following confidential questions.
Name of doctor
Address
Phone number
Have you visited this year?
Yes No
Have you ever been seriously ill or hospitalized? Yes No
Have you ever experienced abnormal bleeding associated with previous extraction, surgery or trauma? Yes No
Please name any medications or non-prescription drugs you are currently taking.
Please check any conditions that apply to your health or health history:
Rheumatic fever Pacemaker/Artificial valves Congenital heart condition AIDS or Positive HIV test
Heart murmur Infectious disease Bruise easily Blood disorders
Arteriosclerosis Artificial joints Heart attack Sinus trouble
Stroke Tumours or growths Trouble hearing Thyroid disease
Blood pressure problems Epilepsy Shortness of breath Inflammatory rheumatism
Hepatitis/jaundice Heart palpitations Cortisone/steroid therapy Angina pectoris
Liver disease Asthma Recent appetite changes Unusual drug reactions
Diabetes Allergies Pregnant (# of months) Other
Are you allergic to or do you have adverse reactions to any of the following?
Aspirin Codeine Erythromycine Tetracyclines
Penicillin Other antibiotics    
What dental condition concerns you now? 

Patient signature _______________________________ (sign in office) Date: __________________________________

Verification: (Please type the verification code exactly as it appears)