Please note that procedures done in the office are not covered by Ontario Health Card Number
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 being treated for any medical condition at the present or have you been treated within the past year?
Have there been any changes in your general health in the past year?
Have you ever been hospitalized for any illness or operations?
Have you ever had an unfavourable reaction following dental treatment?
Have you ever had excessive bleeding requiring special treatment?
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? If yes, please list medications (include prescription medications, non-prescription medication and herbal supplements)
Have you recently used a recreational/street drug ? (if you do not wish to write this down please inform your surgeon verbally). If yes, how often and when was the last use?
Do you have any allergies to medications, latex/rubber, food or other substances? If yes, please list.
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 radiography, 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.
Skip to content Page load link 
Optimized by Seraphinite Accelerator
