Select a Location*Select locationKeswickBradfordOrangevillePatient Type* Adult Child Adult Under Guardianship Email* Self Identification* Man Woman Other Non-Binary OtherName of Patient* First Last Date of Birth* MM slash DD slash YYYY Address*Select Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code*Primary Contact Number*Home PhoneWork PhoneBest number to reach you at?* Home Primary Contact Number Work Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Explain further DetailsWhen was your last medical checkup?*Has there been any change in your general health in the past year?* Yes No Please Explain further DetailsAre you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Explain further DetailsDo you have any allergies?* Yes No Please list allergies belowHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Explain further DetailsDo you have or have you ever had asthma?* Yes No Please Explain further DetailsDo you have or have you ever had any heart or blood pressure problems?* Yes No Please Explain further DetailsDo you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Please Explain further DetailsDo you have a prosthetic or artificial joint?* Yes No Please Explain further DetailsDo you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Explain further DetailsHave you ever had hepatitis, jaundice or liver disease?* Yes No Please Explain further DetailsHave you ever been hospitalized for any illnesses or operations?* Yes No Please Explain further DetailsDo you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) loss of hearing difficulty hearing None of the above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Explain further DetailsDo you smoke or use other nicotine products?* Yes No Are you breastfeeding or pregnant?* Yes No If pregnant, what is the expected delivery date?* MM slash DD slash YYYY Do you have a disability or are a person with visual impairment* Yes No Please Explain further DetailsGeneral Release I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. 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. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature above
