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New Patient Form

Watagan Dental New Patient Form


Please complete this form to help us provide the best care for you. If the patient is unable to complete this form, a next of kin or legal guardian may fill it out on their behalf.

Birthday
Month
Day
Year
Multi-line address

Next of Kin/Legal Guardian (if applicable)

Is the patient able to provide consent for themselves?
Yes
No

If no, please provide details of the next of kin or legal guardian:

Does the guardian have legal authority to make medical decisions for the patient?
Yes
No

Dental History

Have you visited a dentist before?
Yes
No
If yes, when was your last dental visit?
<6m
<12m
1-2 years
>2 years
Do you have any current or past dental issues? (e.g., tooth pain, sensitivity, gum disease)
Yes
No
Are you currently experiencing any dental pain or discomfort?
Yes
No
Have you had any adverse reactions to dental treatments in the past? (e.g., reactions to anesthesia, excessive bleeding)
Yes
No

Initial Medical Screening

Note: If you answer "Yes" to any of the following questions, you will need to complete a separate Medical History Form for a more detailed assessment.

Are you currently taking any medications?
Yes - please complete the medical history form
No
Do you have any current or past medical conditions? (e.g., diabetes, heart disease)
Yes - please complete the medical history form
No
Do you have a disability?
Yes - please complete the medical history form
No
Do you have any allergies?
Yes - please complete the medical history form
No

Disability and Support Needs

Complete this section if the patient has a disability, or if a more detailed assessment is needed in the Medical History Form.

Does the patient have any communication needs? (e.g., sign language, visual aids, simplified language)
Yes
No
Does the patient require any physical accommodations? (e.g., wheelchair access, support for mobility)
Yes
No
Does the patient have a history of violent or challenging behavior?
Yes
No
Does the patient require a support person during appointments?
Yes
No

Additional Information

Are there any other considerations we should be aware of to ensure a safe and comfortable visit? (e.g., sensory sensitivities, anxiety)
Yes
No

Patient Photography Consent

In certain circumstances, photography may be taken as part of your consultation to monitor and assist in managing conditions. These images will form part of your medical record.

I consent to photographs being taken, stored in my dental record.
Yes
No
I consent to my photographs being de-identified and used for medical education, teaching, or research purposes, including publication in medical journals.
Yes
No
I consent to my de-identified photographs being used for website or publicity purposes.
Yes
No

Consent for the Use of an Electronic Scribe

At Watagan Dental, we strive to provide you with exceptional care and focus during your visits. To enhance the quality of our consultations, we use a secure note-taking tool to accurately document our discussions and the outcomes of your appointments for our dental record. No recordings are kept of these conversations.

I consent to the use of an electronic scribe to be used during my appointment.
Yes
No

Acknowledgement

I confirm that the information provided is accurate to the best of my knowledge. If completed by a next of kin or legal guardian, I confirm my authority to provide this information on behalf of the patient.

Date
Month
Day
Year
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