Who should we notify in case of emergency?

Where did you hear about us?

Referring Dentist:

Other Dentists you see:

Family Doctor Information:

Other Doctor's Information:

Please note that procedures done in the office are not covered by Ontario Health Card Number

Do you have dental insurance

Spousal Plan?

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?

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 wear contact lenses?

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

Check any of the following which you presently have (or had), OR if none exists please check 'NONE':

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.

How many packs a day do you smoke?

How much alcohol do you drink in a week?