• Today's Date
     / /
  • Prefix
  • Birthdate*
     / /
  • Height*
  • Units for weight*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Additional Information

  • Select a location:
  • How did you hear about us?

  • Who should we notify in case of emergency?

  • Format: (000) 000-0000.
  • Will you bring X-Rays
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have dental insurance?
  • Spousal/Parental Plan?

  • Please note that procedures done in the office are not covered by OHIP

  • Policy holder's birthdate
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  • Health History

  • The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.

  • Are you completing this form for another person?*
  • Is an interpreter required?*
  • Do you wear contact lenses?*
  • Are you being treated for any medical condition at the present or have you been treated within the past year?*
  • When was your last physical exam?
     - -
  • Do you have any mobility issues and require any accommodations?*
  • Have there been any changes in your general health in the past year? If yes, please explain*
  • Have you ever been hospitalized for any illness or operations? *
  • *
  • Do you have vision or hearing impairment?*
  • Have you ever had an unfavourable reaction following dental treatment?*
  • Have you ever had excessive bleeding requiring special treatment?*
  • Have you ever had an adverse reaction/issue with sedation?*
  • Are you pregnant?*
  • If pregnant?, what is your due date?*
     / /
  • Are you breastfeeding?
  • Check any of the following which you presently have or have had:*
  • Do you have or have you had any other diseases or medical problems not listed on this form?*
  • Are you currently taking any prescription medications, non-prescription medications or herbal supplements?*
  • Do you have any allergies to medications, latex/rubber, food or other substances?*
  • Do you use recreational drugs? For example cannabis marijuana (If you do not wish to write this down please inform your surgeon verbally)*
  • Do you smoke?*
  • Do you consume alcohol?*

  • Terms and conditions

    I hereby state that this medical history is, to the best of my knowledge, accurate and complete. If I ever have any changes in my health, or if my medicines change, I will inform the doctor without fail, if deemed advisable. I grant permission for my physician or dentist to be contacted for details and advice and that my patient information can be disclosed to them. I further authorize the taking of radiographs, photographs, digital images or other diagnostic aids that are appropriate for a thorough evaluation, treatment planning and educational purposes. I understand these may be shared electronically. I further authorize the storage of my records at a secure off-site location.

  • Date (MM/DD/YY)
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  •  
  • Should be Empty: