Medical History

Download

Version
Download 53
File Size 273.74 KB
File Count 1
Create Date December 17, 2018
Last Updated December 17, 2018

Medical History

COVID-19 Patient Screening Form

New Patient Form

Drs. Suzy & Peter Hupfau & Dr. George Ho

510-2425 Oak Street, Vancouver, BC V6H 3S7

Patient Name

Date of Birth

Home Address

City

Province

Postal Code

Home Phone

Cell Phone

Email Address

Employer

Occupation

Business Phone

Who Referred You?

Physician Name

Physician Phone

Previous Dentist

Previous Dentist Phone

Last Dental Visit

Requesting X-rays

YES NO

What Type of X-rays?

When were the X-rays taken?

Primary Insurance

Policy Number

ID Number

Secondary Insurance

Policy Number

ID Number

Chief Concern

Other Notes

Medical History

Medical History

COVID-19 Patient Screening Form

Dental History

Sleep Disordered Breathing Health History

Drs. Suzy & Peter Hupfau & Dr. George Ho

Dental History

Drs. Suzy & Peter Hupfau & Dr. George Ho

ACCEPTANCE

Medical History

Drs. Suzy & Peter Hupfau & Dr. George Ho

ACCEPTANCE

New Patient Form

Drs. Suzy & Peter Hupfau & Dr. George Ho