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HygieneJeric

Emergency ExamDr Braden Zoon

New Patient ExamDr Braden Zoon

Book your appointment for Hygiene lasting [60 minutes].

Any Available Provider

Hygiene 1

Book your appointment for Hygiene lasting [60 minutes].

Earliest available appointment date is on Aug 20, 2026

Available Dates

Available Times

Available times will appear once a date is selected.

Confirm Appointment
Hygiene [60 minutes]

Message For Office(Optional)

20260820,20260826,

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

MEDICAL INFORMATION

Dental professionals treat the mouth and surrounding tissues. Your health history, including conditions which affect your body and the medications you take to treat such conditions, may affect your dental treatment. Please answer the following questions.

Are you currently seeing a Family Physician?

Yes

If so, please enter doctor's name, clinic name, clinic phone number, and date of last visit.

Date of your last Physical Exam:

Have you recently (in the last two years) been hospitalized or had a major operation?

Yes

If yes, please explain.

Are you or could you be pregnant?

Yes

If yes, what is the expected delivery date?

Are you breastfeeding?

Yes

Please indicate which conditions you have or have had. Any further information can be added at the bottom.

Stroke

Chest Pains

Heart Attack/Failure

Artificial Heart Valve

Pacemaker

Blood Disorder(s)

Blood Pressure Issues

Blood transfusion

Hepatitis A

Hepatitis B or C

Liver Disease

Kidney Problems

Dementia

Anaphylaxis

Diabetes

Fainting

Seizures

Arthritis

Artificial Joint(s)

Asthma

Lung Disease

Organ/Medical Transplant

Head or Neck injuries

Mental/Nervous Disorder

Eating disorder

Cancer

Chemotherapy

Radiation therapy

AIDS/HIV Positive

Tuberculosis

Cold sores

Please enter details or any further information.

Are you currently taking or have recently taken any prescription or non-prescription medicine?

Yes

If yes, please list them below:

Please list any diagnosed allergies below and describe your reaction.

Do you have a history of smoking, including wearing a nicotine patch?

Yes

On average, how many packs per day for how many years have you smoked?

Do you consume alcohol or drugs?

Yes

If yes, please advise which substance, and the frequency and amount per week:

Do you vape?

Yes

If yes, please advise which product, and the frequency and amount per week:

DENTAL INFORMATION

In the following sections, please select whichever applies. Please note that during your initial visit, you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Do you have any dental concerns?

Yes

If yes, please explain.

Do you currently have pain in your mouth?

Yes

If so, where? Please describe the pain

Are your teeth sensitive to cold, hot, sweets, or pressure?

Yes

Are you happy with the appearance of your teeth?

Yes

If no, please explain.

Do your gums bleed while brushing and flossing?

Yes

Have you ever had difficulty or discomfort opening or closing your jaw?

Yes

Please give a brief description of your oral hygiene habits (i.e. brushing, flossing, rinses and products used)

Have you had orthodontic treatment (braces)?

Yes

Do you have frequent headaches or migraines?

Yes

Do you clench or grind your teeth?

Yes

Have you ever worn a nightguard or other appliance?

Yes

Have you had any difficult extractions in the past?

Yes

Do you have any sores or lumps in or near your mouth?

Yes

Have you ever had a jaw injury?

Yes

Do you have any loose teeth?

Yes

Does food frequently get caught in your teeth?

Yes

Have you ever had periodontal treatment for your gums?

Yes

Have you ever seen any other dental specialist?

Yes

If so, please advise what specialty, the specialist's name, when you were seen and for what reason.

What is the name of your previous dentist and dental clinic?

What was the date of your late dental check up?

What was the date of your last hygiene appointment?

On a scale of 1/10, how nervous are you to visit the dentist?

INSURANCE INFORMATION

Your coverage details. Please review them and make any necessary adjustments.

Primary Insurance

Subscriber Name

Relationship

Insurance Company Name

Policy #

Subscriber Date of Birth

Subscriber ID #

Div./Group Number

Employer

Additional Notes

Secondary Insurance