General Information

Patient's Name (required)

Preferred Name

If minor, Parents Names

Spouse's Name

Cell Phone

Other Phone

Your Email (required)

Preferred Method of Contact
Call CellText CellEmailOther
If "Other", please describe

Mailing Address

City

Province

Postal Code

Date of Birth (dd/mm/yyyy)

Please attach a copy, or picture, of your "Provincial" insurance card

Please attach a copy, or picture, of your "Extended" insurance card

Occupation

Emergency Contact Number

Emergency Contact Name

Emergency Contact Relationship

How did you hear about us?
GoogleWalk-byMailNewsBillboardFamily-FriendOther
If "Family-Friend", please provide their name

If "Other", please describe

Connect with us on Social Media

Facebook Email Address

Twitter Name

Instagram Name

Medical Health History

Do you have, or have you had, any of the following? (Please check all that apply)
Cancer or tumorHeart ailment or anginaHeart murmur-mitral valve prolapse-heart defectRheumatic fever or rheumatic heart diseaseArtificial joint or valveHigh or low blood pressurePacemakerTuberculosis or other lung problemsKidney diseaseHepatitis or other liver diseaseAlcoholismBlood transfusionDiabetesNeurologic conditionEpilepsy, seizures, or fainting spellsEmotional conditionArthritisHerpes or cold soresAIDS or HIV positiveMigraine headaches or frequent headachesAnemia or blood disordersAbnormal bleeding after extractions, surgery, or traumaHayfever or sinus troubleAllergies or hivesAsthma

Do you smoke or using chewing tobacco?
YesNo

Are you allergic to, or have you reacted adversely to any of the following:
Latex materialsPenicillin or other antibioticsLocal anesthetics-NovocainCodeine or other narcoticsSulfa drugsBarbiturates sedatives or sleeping pillsAspirinOther
If Other, please describe:

Are you taking any of the following:
AspirinAnticoagulants-blood thinnersAntibiotics or sulfa drugsHigh blood pressure medicineAntidepressants or tranquilizersInsulin Orinase or other diabetes drugNitroglycerinCortisone or other steroidsOsteoporosis-bone density medicineOther
If Other, please describe:

Women
Taking hormones or contraceptivesMay be pregnant
If pregnant, provide expected delivery date:

Name of your Physician

Do you have any disease, condition, or problem not listed above

Please add anything else you would like us to know about:

Dental History

Are you anxious about dental treatment? Please explain:

What dental conditions concern you at present?

When was your last dental check up and cleaning:

Were dental x-rays taken at your last dental visit:
YesNo
Have you noticed any signs of the following? (Please check all that apply)
Bleedings GumsSwelling of GumsSore GumsReceeding GumsLoose TeethDrifting of Teeth
Do you have any clicking, popping or pain in your jaw joint?
YesNo
Are you aware of clenching or grinding your teeth?
YesNo
Would you like to improve the appearance of your teeth?
YesNo
Do you floss your teeth?
YesNo
How often do you floss?
Less than once a dayMore than once a dayA few times a weekA few times a monthSeldom
Have you had any complications or difficulty with previous dental treatment? If so, please explain.

By checking the box below, I hereby certify that the Medical and Dental Histories I provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I will assume responsibility for fees associated with those procedures.

I Agree

Δ