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Dental Patient Form

Personal Information

DD slash MM slash YYYY
Address(Required)
Adult Patient
Child Patient

In Case of Emergency, we should notify

Medical Information

Are you being treated for any medical condition at the present or have you been treated with the past year?
(If Yes, please explain)
Has there been any change in your general health in the past year?
(If Yes, please explain)
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
(If Yes, please list medications and dosage)
Do you have any allergies?
(If yes, please explain)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
(If yes, please explain)
Do you have or have you ever had asthma?*(Required)
Do you have or have you ever had any heart or blood pressure problems?*(Required)
Do you have or have you ever had an artificial vales, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*(Required)
(If Yes, please explain)
Do you have a prosthetic or artificial joint?*(Required)
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*(Required)
Have you ever had hepatitis, jaundice or liver disease?*(Required)
Do you have a bleeding problem or bleeding disorder?*(Required)
Have you ever been hospitalized for any illness or operations?*(Required)
(If Yes, please explain)
Have you ever been hospitalized for any illness or operations?*(Required)
(If Yes, please explain)
Do you have or have you ever had any of the following?*(Required)
Are there any conditions or diseases not listed above that you have or have had?*(Required)
(If Yes, please explain)
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)?*(Required)
Do you smoke or chew tobacco products?*(Required)
Are you nervous during dental treatment?*(Required)

Women only

Are you Pregnant?
(If Yes, how many months?)
Nursing?
Taking Birth Control Pills?

Dental Information

Do any of the following cause tooth discomfort?
Are you having any problems that require immediate attentions?*(Required)
(If Yes, please explain)
Do your gums bleed when you brush your teeth?
Have you noticed an loose teeth?
Do you clench or grind your teeth?
Have you been diagnosed with sleep apnea?
Have you ever had orthodontic treatment (Braces or Invisalign?)
Are you interested in straightening your teeth?
Are you interested in whitening?
Are you interested in crowns or implants?

Insurance Information

Insurance Coverage
Secondary Insurance (If Applicable)
DD slash MM slash YYYY
DD slash MM slash YYYY

Cancellations & Missed Appointments

Your appointment time has been reserved exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient. Appointments that are cancelled with less than 48 hours notice and missed appointments are subject to $50.00 fee. This fee will be due in full prior to your next scheduled appointment.

General Release

I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental clinic. I authorize the dentist to perform all diagnostic procedures including and not limited to x-rays and photographs, as may be required to determine necessary treatment, and to perform necessary or advisable treatment. I understand that information provided form or to my medical doctor or another healthcare provider may be necessary. I have been advised of the privacy policy of the clinic and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that my dental insurance may not cover entirely the total fee of services provided. 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.
Clear Signature
This field is for validation purposes and should be left unchanged.

Are you struggling with dental issues such as toothaches, gum problems, or missing teeth that are affecting your oral health and overall well-being?

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Hours of Operation
  • Sun/Mon/Tues :
    Closed
  • Wednesday :
    2:00 pm – 8:00 pm
  • Thursday :
    2:00 pm – 8:00 pm
  • Friday :
    9:00 am – 4:00 pm
  • Saturday :
    8:00 am – 3:00 pm
    (one saturday/month)
  • Receptionist/admin in clinic:
  • Mon/Tues :
    10:00 am – 3:00 pm

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For emergency cases – (604) 944-0100