Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Welcome to Archibald Dental CentreWe value your health – and your time. Whatever your dental care needs, we can help. Adult Patient Information Form Adult Patient Information Name Last Name First Date of Birth Address Postal Code Phone (home) Phone (other) Employer Phone (work) Ideal mode of contact Home Work Cell Email Insurance carrier Plan ID Name of subscriber Subscriber’s date of birth Whom may we thank for this referral? Medical History Physician's name Have you ever had any serious illnesses or operations? Yes No Are you presently under any medical treatment? Yes No Are you taking any medications at present or recently? Yes No Have you taken any Steroids or Cortisone in the last three years? Yes No Do you suffer from any allergies? Yes No Have you ever been told that you need antibiotics before dental treatment? Yes No Have you ever had any of the following (please check where applicable) Heart disease Diabetes High/Low Blood Pressure Epilepsy HIV/AIDS Hepatitis Cancer Rheumatic Fever Asthma Dental History Do your gums bleed when brushing? Yes No Do you suffer from pain or swelling of your gums? Yes No Does food catch between your teeth? Yes No Do you clench or grind your teeth? Yes No Is there anything about the appearance of your teeth that bothers you? Yes No Do you experience any of the following JAW problems? (please check where applicable) Clicking Pain Difficulty opening/closing Difficulty in chewing There is a $75.00 charge for appointments that are cancelled with less than 48 HOURS NOTICE (2 Full Business Days) Archibald Dental Centre is happy to help you receive your maximum dental benefit provided under your insurance plan. The amount of coverage you receive is dependent on the agreement between your employer and the insurance company. However, there are many different plans available and we cannot be experts on all of them. As a patient, I understand that I am financially responsible for the entire treatment or any portion not covered by insurance and that payment is due on the date of service. Patient Signature Clear Date reCAPTCHA If you are human, leave this field blank. Submit Δ Patient Information Forms Fill out a patient information form before your first visit. Adult Form Child Form Book Your Dental Care Today! New Patient Check Up & Cleaning Existing Patient Check Up & Cleaning Contact Us
