Receptionists are available: Monday to Thursday: 8:00am-7:00pm Friday: 8:00am-4:00pm Saturday and Sunday: Closed
The following information is required by the Dentist to assist in proper diagnosis and treatment.
Dr.Mr.Mrs.Ms.Miss.
First Name *
Last Name *
Middle Name
Please list other family members attending this office:
Full Address *
Email *
Home Phone
Business
Cell
Date of birth *
Sex *
In case of emergency *
Your Employer/School
Occupation
Dental insurance YesNo
Name of Company
Certificate #
Policy #
Division #
Do you have dual coverage?
OHIP #
Person responsible for this account? Same as aboveOther person
Other person (details)
Whom may we thank for referring you?
Date of your last medical examination?
Name of family physician
Is your physician treating you now? YesNo
Are you on medication? YesNo
Do you have drug allergies? YesNo
Are you pregnant? YesNo
Have you ever been treated for:
Respiratory diseaseRheumatic feverScarlet feverShortness of breathThyroid problemsKidney problemsOsteoporosisHigh blood pressureLow blood pressureAbnormal bleedingNervous problemsBlood disordersVenereal diseaseArtificial jointsHepatitisAnemiaSinusArthritis
DiabetesCancerPacemakerHerpesStrokeUlcerEpilepsyAsthmaHeart MurmurAids or HIV positiveTuberculosisLiver problemsHeart diseaseDizzy spellsChest painGeneral allergiesDiseases of eyes, ears, nose or throat
Is there anything we should know about your health?
Are you having discomfrot at this time? YesNo
Have you been under regular care by a dentist? YesNo
What was done at the time?
Do your gums feel tender or swollen? YesNo
Are you awware of any lump or swelling in your mouth? YesNo
Do you wish to keep your natural teeth? YesNo
Have you ever had a problem with local or general anesthetic? YesNo
Are you tense during dental visits? YesNo
Would you be interested in improving the appearance of your teeth? YesNo
Describe in your own words what you would like done to your teeth:
Do you currently experience...
Loose teethSensitive teethEaracheHeadacheSpaced or crooked teethBleeding gumsBad breathe
Neck painUnexplained nose bleedsUnsatisfactory denturesSore gumsPopping or clicking in the jaw jointsMissing teethGagging
Additional medication
I, , consent to the performing of dental procedures agreed to be necessary or advisable for myself or , and, further, I will assume responsibility for fees associated with those procedures.
I agree
All accounts payable when services are rendered. Interest charged on overdue accounts.
I authorize release, to my insurance company/plan administrator information contained in claims submitted electronically.
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