New Patient Form

Download our new patient form if you'd prefer to bring it in.

01Patient Information

Preferred Name

Please enter a valid preferred name.

Last Name

Please enter a valid last name.

Date of Birth

Please enter a valid date of birth.

Telephone Number

Please enter a valid telephone number.

Cell Number

Home Address

Please enter a valid home address.

City

Postal Code

Health Card Number

Employment

Employer

Occupation

Emergency Contact

Emergency Contact Name

Please enter a valid emergency contact name.

Emergency Contact Phone

Please enter a valid emergency contact phone.

Relationship

02Medical References

Dentist Information

General Dentist Name

Family Physician Information

Family Physician Name

Pharmacy Information

Pharmacy

Do you have insurance coverage?

Yes

Primary Insurance

Primary Insurance Provider

Primary Policy Number

Primary ID Number

Secondary Insurance

Secondary Insurance Provider

Secondary Policy Number

Secondary ID Number

Secondary Policy Holder Name

Secondary Policy Holder Birthdate

* I understand that the answers to these questions are necessary to provide me with the best possible care and favourable outcome. I have answered all questions truthfully and to the best of my knowledge. I consent to Fourth Ave Endodontics obtaining any other information from other practitioners who are currently or have treated me in the past that will be necessary in providing proper care.

* I understand that the total payment of dental services is my responsibility, and not that of the insurance company. Payment is due when services are rendered.

Address

Suite 237 - 1338 Fourth Ave, St. Catharines

Phone

Tel: (289) 362 - 2980

Fax: (289) 362 - 3382

E-mail

info@fourthaveendodontics.com

Hours

Monday - Friday: 8am - 5pm

Payment Options

Your consultation appointment will provide you with a predetermination outlining the costs of your upcoming treatment. Payment will be due at the time service is rendered. We accept Visa, Mastercard, Debit, American Express or cash payments. If you have insurance coverage, we can assist you in submitting your claim electronically or provide you with the forms necessary for you to submit independently.

New Patient Form

New Patient Form

01Patient Information

Employment

Emergency Contact

02Medical References

Dentist Information

Family Physician Information

Pharmacy Information

Do you have insurance coverage?

Primary Insurance

Secondary Insurance

03Dental Information

Personal Health

Are you being treated for any medical condition (currently or within the last year)?

Has there been any change in your general health in the past year?

Do you have any conditions that may affect your immune system (e.g. leukemia, HIV, lupus)?

Are you undergoing any therapies that could affect your immune system (e.g. radiotherapy, chemotherapy)?

Are you currently taking any steroids or cortisone?

Do your ankles, feet or hands swell?

Allergies

Are you allergic to any medications?

Are you allergic to latex?

Are you allergic to rubbers?

Are you allergic to any metals?

Have you ever had any peculiar or adverse reactions to any medications or injections?

Current Medications

Do you have diabetes?

Do you have, or have had, any of the following conditions (please select all that apply):

Any medical conditions not listed:

Are there any diseases or medical conditions that run in your family?

Do you have a bleeding problem or bleeding disorder?

Do you have or have you had a replacement or repair of a heart valve or stent?

Do you have or have you ever had an infection of the heart?

Have you had an organ transplant?

Do you have a heart condition from birth (e.g. congenital heart disease)?

Do you have or have you ever had any blood pressure problems?

Do you have a prosthetic or artificial joint?

Have you ever been hospitalized for an illness/operation within the past 5 years?

Have you ever had an injury to your face or jaw?

Do you smoke or chew tobacco products?

Are you taking any herbal supplements of any kind?

Do you take any recreational drugs on a regular basis?

Have you ever had root canal/endodontic therapy?

If yes:

How would you rate your previous experience?

Have you ever been recommended antibiotic coverage prior to surgery or dental procedures?

Have you ever had abnormal bruising/bleeding associated with a dental procedure?

Have you ever had an adverse reaction to dental freezing/local anesthetic?

Where would you rate your level of nervousness about dental treatment?

Is there anything else about your health we should be aware of?

WOMEN:

Are you pregnant?

Are you breastfeeding?

Approximate Due Date

CHILDREN:

Are there any immunizations the child is not up to date with?

Address

Phone

E-mail

Hours

Payment Options

Book a consultation with us today.