Our Location

153 Hampton Road
Rothesay, NB
506 849-3322
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About Oakvillelane Dental

The following Patient Chart has been provided for your convenience. If you would like to download the form to bring with you on your next visit, please click here.

Name *
Email *
Date of Birth *
Dental Plan
Address
Postal Code

Phone
Work
Cell
Family Doctor
Occupation
Referred By

Insurance

Company
Policy #
ID/Certificate #

Questionnaire

What is your current dental problem?

What is your main dental concern?

If you could, what would you change about your teeth? Colour/Position/Shape?

Do you floss? Yes/No How often?

Coffee/Tea/Pop drinker? How often?

Do you get Canker Sores/Cold Sores? How often?

Do you have any oral habits? Nail Biting/Thumb Sucking/Pen Chewing?

Do you Clench/Grind your teeth? Do you have pain in your jaw? Headaches? Explain:

Medical Questionnaire

Have you had any reactions to drugs or medicines? To what? Explain:

Do you have any allergies? ie penicillin/latex?

Is your physician treating you for any current conditions?

What medication if any are you taking now?

Have you taken cortisone or steroids?

Have you had any major operations or been hospitalized in the last 6 months?

Do you have any of the following?

Abnormal Bleeding
Shortness of Breath
Asthma
Heart Murmur
Heart Disease
High Blood Pressure
Extreme loss/gained Weight
Tumors/growths
Hepatitis A/B/C

Blood Disorders/Anemia
Radiation Therapy
Chemotherapy
Epilepsy
Diabetes Type I/II
Rheumatic Fever
Thyroid trouble
Kidney trouble
Tuberculosis

Have you had any major operations or been hospitalized in the last 6 months?

General Release

I, the undersigned, confirm that all information given is true. I consent to the performing of the dental/surgical procedures as agreed or advised to be necessary; this includes the use of local anesthetic /nitrous sedation. I assume the responsibility of all fees associated with those procedures.

Third party involvement (dental insurance) will be submitted as a courtesy to you. Your portion of coverage is payable at the time of your appointment, any changes in your coverage at the time of billing is your esponsibility. Dental Insurance is arranged between you and your employer; we do not have access to individual policies/ coverage.All information is held in confidence in accordance of the Privacy Act.

Appointment Book

Patient Chart