NAME: MR./MISS/MRS./MS./DR.* Legal Name

IN CASE OF EMERGENCY. WE SHOULD NOTIFY:

DATE OF BIRTH (DAY /MONTH/YEAR):

RELATIONSHIP:*

ADDRESS (HOME):*
Unit Number:
Street Name:
Your City:
Province:
Postal Code:

DAY-TIME PHONE:*

Email:*

NAME OF FAMILY DOCTOR:*

CELL PHONE:*

PHONE OR ADDRESS:*

HOME PHONE:

ADDRESS (BUSINESS):

(1) NAME OF MEDICAL SPECIALIST:*

OCCUPATION:

AREA OF SPECIALIST:*

WHO REFERRED YOU TO OUR OFFICE?*
Please Select Referral SourceFlyer in MailGoogle ReviewsLive in NeighbourhoodWebsiteFriend/Family
Please specify your Friend/Family:

PHONE OR ADDRESS:*

(2) NAME OF MEDICAL SPECIALIST:*

AREA OF SPECIALIST:*

PHONE OR ADDRESS:*

The following information is required to enable us to provide you with the best possible dental care.
All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the
questions and explain any that you do not understand. Please fill in the entire form.

1. Do you have insurance coverage?*
YesNo

If yes, please provide following details

2. Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain?*
YesNoNot Sure/Maybe

3. When was your last medical checkup?*

4. Has there been any change in your general health in the past year?* If yes, please explain.
YesNoNot Sure/Maybe

5. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?* If yes, please list them.
YesNoNot Sure/Maybe

7. Have you ever had a peculiar or adverse reaction to any medicines or injections?* If yes, please explain.
YesNoNot Sure/Maybe

8. Do you have or have you ever had asthma?*
YesNoNot Sure/Maybe

9. Do you have or have you ever had any heart or blood pressure problems?*:
YesNoNot Sure/Maybe

10. 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
YesNoNot Sure/Maybe

11. Do you have a prosthetic or artificial joint?*
YesNoNot Sure/Maybe

12. Do you have any conditions or therapies that could affect your immune system?* (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)
YesNoNot Sure/Maybe

13. Have you ever had hepatitis, jaundice or liver disease?*
YesNoNot Sure/Maybe

14. Do you have a bleeding problem or bleeding disorder?*
YesNoNot Sure/Maybe

15. Have you ever been hospitalized for any illnesses or operations?* If yes, please explain
YesNoNot Sure/Maybe

16. Do you have or have you ever had any of the following?* Please check.
chest pain, anginarheumatic feverpacemakersteroid therapyseizures (epilepsy)heart attackmitral valve prolapselung diseasediabeteskidney diseasestroke, TIAtuberculosisstomach ulcersthyroid diseaseshortness of breathheart murmurcancerarthritisdrug/alcohol/cannabis use or dependencyosteoporosis medications (e.g. Fosamax, Actonel)

17. Are there any conditions or diseases not listed above that you have or have had?* If yes, please explain.
YesNoNot Sure/Maybe

18. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?*
YesNoNot Sure/Maybe

19. Do you smoke or chew tobacco products?*
YesNoNot Sure/Maybe

20. Are you nervous during dental treatment?*
YesNoNot Sure/Maybe

21. Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?*
YesNoNot Sure/Maybe

22. Do you identify as a patient with a disability? If yes, please explain*.
YesNoNot Sure/Maybe

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature*:

Date:

Dentist Signature:

Date: