subject_line
First Name
*
Last Name
*
Street Address
*
Address Line 2
City
*
Province
*
Ontario
Postal Code
*
Phone Number
*
Date of Birth
*
Gender
Male
Female
Other
Email Address:
Health Card Number:
Occupation:
PLEASE PROVIDE THIS: WE DO NOT GET THIS FROM YOUR FAMILY DENTIST
Primary Dental Insurance
Insurance company name
group/policy number
ID/certificate number
*If under a spouse, please provide their full name and date of birth
Secondary Dental Insurance
Insurance Company Name
group/policy number
ID/certificate number
*If under a spouse, please provide their full name and date of birth
Referring Dentist
Have you ever had a serious illness, operation, or been in the hospital?
*
No
Yes
If Yes, please explain
If Yes, please explain
Are you currently being treated for any medical condition?
*
No
Yes
If Yes, please explain
If Yes, please explain
Have you had a medical examination in the last year?
*
No
Yes, please explain
Yes, please explain
Are you presently taking any medications?
*
No
Yes, please list
Yes, please list
Pharmacy Phone Number:
Are you a smoker?
*
Yes
No
Do you have or have you ever had any of the following?
*
Rheumatic Fever
Heart Attack
Pacemaker
High Blood Pressure
Heart Murmur
Liver Disease
Kidney Disease
Blood Disorder
Anemia
HIV
Jaundice
Lung Disease
Sinusitis
Joint Replacement
Hepatitis
Epilepsy
Radiation Therapy
Venereal Disease
Mental Health Illness
Thyroid Disease
Diabetes
Cancer
Gastrointestinal Disease
Nervous Disorder
NONE
If anything not mentioned please note:
If anything not mentioned please note:
Are you allergic to any medication?
*
No
Yes
If yes please explain
If yes please explain
Do you have any allergies or sensitivies?
*
No
Yes
If yes please explain
If yes please explain
Do you require antibiotics before all dental procedures?
*
Yes
No
Do you bleed abnormally?
*
Yes
No
WOMEN: are you pregnant or trying to get pregnant?
No
Yes
Yes
Is there anything that the dentist should know regarding your medical history that has not been mentioned?
No
Yes, please explain
Yes, please explain