Select a Location*
Are you a new or current patient?*
New Patient Current Patient Other
Patient Contact Information
Patient Type
Adult Child Adult Under Guardianship
Name of Guardian
Gender
Male Female Other
Name of Patient
Date of Birth
Address
Email
Home Phone Number
Cell Phone Number
Best way to contact you:
Best way to contact you:
Home Cell Work
Family Physician
Specialist Name
Emergency Contact
Emergency Contact Phone Number
Insurance Information
Primary Insurance Company
Insurance Policy Holder
Self Spouse Parent/Guardian
Insurance Company Name
Name of Insurance Policy Holder
Policy Holder Date of Birth
Group Policy/Plan Number
ID/Certificate Number
Secondary Insurance Company Information
Insurance Policy Holder
Self Spouse Parent/Guardian Other
Insurance Company Name
Name of Insurance Policy Holder
Policy Holder Date of Birth
Group Policy/Plan Number
ID/Certificate Number
Financial Information
Person responsible for account
Self Spouse Parent/Guardian Other
Name of Guardian
Preferred Method of Payment
Interact Visa Cash Mastercard
Dental History
Date of your last dental exam
Date of your last dental cleaning
Date of your last dental xrays
Please check any of the following problems that may apply to you.
Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing Headaches, earaches or neck pain Jaw joint pain (clicking/cracking) Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, chipped or shifting teeth Bad breath or bad taste in your mouth
Do you have, or have you had any of the following?
Dentures Orthodontics Partial dentures Periodontal (gum) treatments
If you could change your smile, you would….
Make your teeth brighter Make your teeth straighter Close gaps between teeth Replace metal fillings with natural tooth coloured fillings Repair chipped teeth Replace missing teeth Replace old crowns that don’t match Have a smile makeover
How important is your dental health to you?
1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest rating
Where would you rate your current dental health?
1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, with 10 being the highest rating
Why are you leaving your previous Dentist?
What, if anything, in the past has kept you from having dental treatment?
What is the most important thing about your future smile and dental health?
What is most important thing to you about your upcoming visit?
Medical History
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year?*
Yes No
Has there been any change in your general health in the past year?*
Yes No
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
Yes No
Do you have any allergies?*
Yes No
Have you ever had a peculiar or adverse reaction to any medicines or injections?*
Yes No
Do you have or have you ever had asthma?*
Yes No
Do you have or have you ever had any heart or blood pressure problems?*
Yes No
Do 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
Do you have a prosthetic or artificial joint?*
Yes No
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
Yes No
Have you ever been hospitalized for any illnesses or operations?*
Yes No
Do you have or have you ever had any of the following? Please check all that apply.
Yes No
Do 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)
Are there any conditions or diseases not listed above that you have or have had?
Yes No
Do you smoke or use other nicotine products?
Yes No
Are you breastfeeding or pregnant?
Yes No
Do you identify as a patient with a disability?
Yes No
General Release
I agree to your cancellation policy and understand that two (2) business days notice is required to rechedule my appointment.
I agree I do not agree
I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history 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.*
Clear
Use your mouse or finger to draw your signature above
Date
