Skip to content
For Professionals
Our Solutions
Expand
Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
Expand
Snoring
Sleep Apnea
Sleep Assessment
Forms & Resources
Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
Book Now
For Professionals
Toggle Menu
New Patient Form
Step
1
of
3
- Personal Information
33%
Personal Information
Name
(Required)
First
Last
Cell Phone Number
(Required)
Home Phone Number
Gender
(Required)
Male
Female
Other
Date of Birth
(Required)
DD slash MM slash YYYY
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Name Of Your Family Dentist
(Required)
Are you being referred by the above dentist?
(Required)
Yes
No
Name Of Your Family Doctor
(Required)
Name Of Your Family Doctor's Practice
(Required)
Insurance Information
Do you have insurance coverage?
(Required)
Yes
No
Planholder Name
(Required)
First
Last
Planholder Date of Birth
(Required)
DD slash MM slash YYYY
Plan/Group Number
(Required)
ID/Certificate Number
(Required)
Insurance Carrier
(Required)
Do you have a second insurance plan?
(Required)
Yes
No
Planholder Name
(Required)
First
Last
Planholder Date of Birth
(Required)
DD slash MM slash YYYY
Plan/Group Number
(Required)
ID/Certificate Number
(Required)
Insurance Carrier
(Required)
Medical & Dental Information
Do you have any allergies?
(Required)
Yes
No
Please list your allergies below
(Required)
Have you been advised by your doctor to take antibiotics before dental treatment?
(Required)
Yes
No
If yes, why?
(Required)
Are you taking any medications at this time?
(Required)
Yes
No
If yes, what medications are you taking?
(Required)
Do you have a bleeding problem or a bleeding disorder?
(Required)
Yes
No
Do you have any heart or blood pressure problems?
(Required)
Yes
No
Do you have a pacemaker or prosthesis?
(Required)
Yes
No
Do you have any conditions that could affect your immune system?
(Required)
Yes
No
(i.e. leukemia, AIDS, HIV infection, radiation therapy, chemotherapy)
Have you ever had hepatitis, rheumatic fever, tuberculosis?
(Required)
Yes
No
Do you have any of the following health conditions?
Seizures
Diabetes
Sinus problem
Thyroid disorder
Arthritis
Stomach Ulcers
Periodontal Disease
Select All
Do you have any health conditions or diseases not listed that we should be aware of?
Yes
No
If yes, please list your health conditions or diseases below
(Required)
Signature
(Required)
Want To Improve Your Sleep?
Book Your FREE Consultation
Book Now
Our Solutions
Toggle child menu
Expand
Treatment Options
Oral Appliance Therapy
Snoring and Sleep Apnea
Toggle child menu
Expand
Snoring
Sleep Apnea
Sleep Assessment
Forms & Resources
Toggle child menu
Expand
Patient Care
Pre-Treatment Sleep Questionnaire
New Patient Form
Insurance Package
Notifications
