Monday 9AM to 7PM Tuesday 9AM to 7PM Wednesday 9AM to 7PM Thursday 9AM to 7PM Friday 9AM to 5PM Saturday 9AM to 5PM Sunday – CLOSED

Payment is due at the time of service. We accept the following payment methods: Cash Visa MasterCard Amex Interac Etransfer (info@dolphindentistry.com)

New Patient Form - Dolphin Dentistry

Q: EMERGENCY DENTAL CARE

If you are in need of EMERGENCY DENTAL CARE, please call us at +1(613) 234-7979. Guaranteed same day response.

318 McLeod St, Ottawa, ON K2P 1A3
+1(613) 234-5758
info@dolphindentistry.com
EMERGENCY DENTAL

Registration Information

Title

Mr.
Mrs.
Ms.
Miss

Patient is *

Adult
Child

Patient Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Work Phone

Cell Phone

Other Phone

Email Address *

Occupation

Emergency Contact

Emergency Contact Name

Family Doctor or Specialist

Family Doctor / Specialist Name

Family Doctor / Specialist Phone

Relationship to Patient

Insurance Information

Primary Insurance Subscriber

Primary Subscriber Name

Primary Subscriber Date of Birth

Primary Subscriber Relationship

Self
Spouse
Other

Primary Insurance Company

Primary Policy Number

Primary Division / Sector

Primary Subscriber ID

Secondary Insurance Subscriber

Secondary Subscriber Name

Secondary Subscriber Date of Birth

Secondary Subscriber Relationship

Self
Spouse
Other

Secondary Insurance Company

Secondary Policy Number

Secondary Division / Sector

Secondary Subscriber ID

Medical History

Have you had a serious illness requiring hospitalization or extensive care? *

If yes, what year?

Have you been hospitalized in the last 5 years? *

Are you currently under the care of a physician or specialist? *

Have you had a medical exam in the past year? *

Do you take any prescription or over-the-counter medications? *

If yes, please list all medications or provide the contact of your pharmacy

Do you have any allergies? (e.g., to food, medicine, etc.) *

If yes, please specify your allergies

Other medication reactions (please specify)

Do you have an EpiPen?

Do you bruise easily or bleed more than normal? *

Have you ever had any organ implants or medical implants? *

Have you ever fainted? *

Do your ankles, feet, or hands swell? *

Do you experience shortness of breath or chest pain when walking or climbing stairs? *

Do you have frequent headaches? *

Do you have HIV/AIDS or have you ever tested positive for HIV? *

Do you have Hepatitis A, B, or C? *

Have you had any of the following conditions? *

Other condition (please specify)

Is there any other disease, condition, or health issue we should be aware of? *

For Women Only

Are you pregnant or suspect you might be?

Are you using birth control?

Dental History

Is there a dental problem you'd like to address right today? *

Do you visit the dentist regularly? *

Last dental visit (mm/yyy)

Last cleaning (mm/yyy)

How often do you brush your teeth?

How often do you floss your teeth?

Do your gums bleed when you brush or floss? *

Do your teeth feel sensitive? (Check all that apply)

Hot
Cold
Biting
Sweets

Do you feel you have bad breath sometimes? *

Have you ever had surgery, injury, or X-ray therapy to your face or jaw? *

Do you have pain in your jaw joints or get headaches? *

Does your jaw click or pop when you open your mouth wide? *

Do you grind your teeth during the day or at night? *

Do you smoke or use other tobacco products? *

Have you ever had growths or sores in your mouth? *

Do you have any previous dental treatment concerns? *

Are you happy with the appearance of your teeth? *

Please list any other dental concerns or questions you may have

Office Policy

We reserve your appointment time especially for you. If you can't make it, please let us know 48 hours in advance. Otherwise, we may need to charge for the missed appointment.

Patient Release

By signing below, I confirm that the information I've provided is accurate and complete. I've had the opportunity to ask questions about my medical and dental history. I authorize the dentist to perform the necessary procedures and understand that my medical doctor may need to be contacted if necessary. I'm also responsible for the payment of services provided.

Patient Consent *

I confirm the above information is accurate and I agree to the office policy and patient release statement.

Patient (or Parent/Guardian) Name *

Date *

Optional Questions

Are you available on short notice for future appointments?

How did you hear about us?

New Patients Are Always Welcome

OFFICE INFORMATION

OFFICE HOURS

Monday 9AM to 7PM
Tuesday 9AM to 7PM
Wednesday 9AM to 7PM
Thursday 9AM to 7PM
Friday 9AM to 5PM
Saturday 9AM to 5PM
Sunday – CLOSED

EMERGENCY DENTAL CARE

If you are in need of EMERGENCY DENTAL CARE, please call us at +1(613) 234-7979. Guaranteed same day response.

DIRECT BILLING SERVICES

Our office does Direct Billing to most Extended Health Care Insurance Plans. Please call ahead to ensure that we are able to provide that service to you.

PAYMENT METHODS

Payment is due at the time of service.

We accept the following payment methods:

Cash
Visa MasterCard Amex
Interac
Etransfer (info@dolphindentistry.com)

PARKING

Free parking is available for Dolphin Dentistry patients.

Patient parking is located beside Apartment Complex 320. The last 6 parking spots at the end of the parking lot are reserved exclusively for Dolphin Dentistry patients.

If you need any assistance locating the parking area, please contact our reception team.

Thank you!

New Patient Form