Register – Dr. C.P. Giri dentistry

Dr. C.P. Giri dentistry

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Call: (905) 770 2006
Call: (905) 770 2006

New Patient Registration Form

Patient First name

Patient Last Name

Preferred Name

Gender

Male Female

Family Status

Married Single Child Other

Date Of Birth

Previous Visit (if known)

Home Phone

Mobile

Work Phone Number

Best time to call

Address

City

Province

Postal Code

In case of an emergency we should notify, name, Relationship, Daytime Phone number

Your primary care physician's Name, Address & Phone number

Would you like to speak to the doctor privately about any medical condition?

Yes No

Are you being treated for any medical condition at the present or have you been treated in the present or have you been treated in the past year? if so why?

Do you have any allergies?

Yes No

If you answered yes, please list using the categories below

Penicillin Erythromycin Sulfa Metal Aspirin Local Anaesthetic Latex Other Foods Other e.g. hayfever Codiene

Have you ever had a peculiar or adverse reaction to any medications or injections if so explain?

Do you have or have you ever had asthma?

Yes No

Do you have or have you ever had heart murmur,mitral valve prolapse or rheumatic fever?

Yes No

Do you have a prosthetic or artificial joint?

Yes No

Have you ever been advised by your doctor to take any antibiotics before dental treatment?

Yes No

If you answered yes, please list using the categories below

e.g. leukemia radiotherapy AIDS chemotherapy? HIV infection

Have you ever hepatitis,jaundice or have liver disease?

Yes No

Do you have a bleeding problem or bleeding disorder?

Yes No

Have you ever been hospitalized for any illness or operations?

Yes No

If yes please explain.

Do you have or have had any of the following? Please check.

Pre-Medication Allergy - Latex Allergy - Erythromicin Arthrities Blood Disease Diabetes Epilepsy Gastro-Intestinal Hay Fever Hearing Disabled Hepatitis A HIV+ (AIDS) Kidney Disease Mental Disorders Pacemaker Respiratory Arthritis STD Thyroid Disease Tumors

See Patient Notes Allergy - Penicillin Allergy - Local Anesth Artificial Joints Cancer Dizziness/Fainting Excessive Bleeding Glaucoma HBP Heart Disease Hepatitis B Hives LBP Multiple Sclerosis Pragnancy Sinus Problems Stomach Problems TMJ Ulcers

Allergy - *See Notes Allergy - Sulfa Anemia Asthma Contraceptive Use Emphysema Excessive Bruising Option 24 Head Injury Heart Murmur Hepatitis C Jaundice Liver Disease Nervous Disorders Radiation Treatment Skin Rash Stroke Tuberculosis Wheelchair

Are you nervous during dental treatment?

Yes No

For women only: Are pregnant?

Yes No

If yes, how many months?

Are you nursing?

Yes No

Are you taking any birth control pills?

Yes No

To the best of my knowledge, the above information is correct. *

Yes No

Signature (Type your name)

Date

18159

Clinic Hours

Tuesday: Appointment Only
Wed - Fri: 10.00AM - 7.00PM
Alternative Saturday: 9.00AM - 3.00PM
Sun - Mon & Alternative Thursday: Closed

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Contact

Get In Touch

9791 Bayview Avenue,

Richmond Hill,
Ontario, L4C 9X7

Tel: (905) 770 2006

Dental Emergency: 416 485 7121 / 416 919 9911

Fax: (905) 508 7887

info@Drcpgiri.com

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