Are you a current or new patient?
How did you hear about our clinic?*
Patient Contact Information
Gender
Best way to contact you:
Marital Status
Insurance Information
Primary Insurance Company
Insurance Policy Holder
Secondary Insurance Company Information
Insurance Policy Holder
Financial Information
Person responsible for account
Preferred Method of Payment
Dental History
Do you have, or have you had any of the following?
How important is your dental health to you?
Where would you rate your current dental health?
Medical History
Are you currently being treated for any medical condition or have you been treated within
the past year?*
Has there been any change in your general health in the past year?*
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
Do you have any allergies?*
Have you ever had a peculiar or adverse reaction to any medicines or injections?*
Do you have or have you ever had asthma?*
Do you have or have you ever had any heart or blood pressure problems?*
Do you have or have you ever had a replacement or repair of a heart valve, an infection of
the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart
disease) or a heart transplant?*
Do you have a prosthetic or artificial joint?*
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia,
AIDS, HIV infection, radiotherapy, chemotherapy)?*
Have you ever had hepatitis, jaundice or liver disease?*
Have you ever been hospitalized for any illnesses or operations?*
Do you have or have you ever had any of the following? Please check all that apply.
Are there any conditions or diseases not listed above that you have or have had?
Do you smoke or use other nicotine products?
Do you identify as a patient with a disability?
General Release
I agree to your cancellation policy and understand that two (2) business days notice is
required to rechedule my appointment.
I, the undersigned, certify that I have provided an accurate and complete personal and
medical-dental history and have not knowingly omitted any information. I have had an
opportunity to ask questions and receive answers to any questions regarding my
medical-dental history. I authorize the dentist to perform diagnostic procedures as may be
required to determine necessary treatment. I understand that the information provided from
or to my medical doctor or another health care provider may be necessary, and I consent to
the release of this information. I understand that responsibility for payment of the dental
services for myself and my dependents is mine, and I assume responsibility for fees
associated with these services. The patient agrees that the relationship between himself or
herself and the dentist shall be governed and construed in accordance with the laws of the
province of Ontario.*
Signature
