Are you a current or new patient?
How did you hear about our clinic?*
Social Media
Search Engine
Lives In Area
Friend/Family
Patient Referral
Employee Referral
Event
Other:
Patient Contact Information
Patient Type
Adult
Child
Adult Under Guardianship
Gender
Male
Female
Other
Date of Birth
Best way to contact you:
Home
Cell
Work
Marital Status
Single
Married
Common Law
Other
Insurance Information
Primary Insurance Company
Insurance Policy Holder
Self
Spouse
Parent/Guardian
Policy Holder Date of Birth
Secondary Insurance Company Information
Insurance Policy Holder
Self
Spouse
Parent/Guardian
Other
Policy Holder Date of Birth
Financial Information
Person responsible for account
Self
Spouse
Parent
Other
Preferred Method of Payment
Interac
Visa
Cash
Mastercard
Dental History
Do you have, or have you had any of the following?
How important is your dental health to you?
1
2
3
5
6
7
8
9
10
Where would you rate your current dental health?
1
2
3
5
6
7
8
9
10
Why are you leaving your previous
Dentist?
What, if anything, in the past has kept you from having dental
treatment?
What
is the most important thing about your future smile and dental health?
What is most
important thing to you about your upcoming visit?
Medical History
Are you currently being treated for any medical condition or have you been treated within
the past year?*
Yes
No
Has there been any change in your general health in the past year?*
Yes
No
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
Yes
No
Do you have any allergies?*
Yes
No
Have you ever had a peculiar or adverse reaction to any medicines or injections?*
Yes
No
Do you have or have you ever had asthma?*
Yes
No
Do you have or have you ever had any heart or blood pressure problems?*
Yes
No
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?*
Yes
No
Do you have a prosthetic or artificial joint?*
Yes
No
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia,
AIDS, HIV infection, radiotherapy, chemotherapy)?*
Yes
No
Have you ever had hepatitis, jaundice or liver disease?*
Yes
No
Have you ever been hospitalized for any illnesses or operations?*
Yes
No
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?
Yes
No
Do you smoke or use other nicotine products?
Yes
No
Do you identify as a patient with a disability?
Yes
No
General Release
I agree to your cancellation policy and understand that two (2) business days notice is
required to rechedule my appointment.
I agree
I do not agree
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
Submit
Form
