A parent/guardian will be responsible for decisions regarding my treatment
    First Name:
    Middle Name:
    Last Name:
    Postal Code:
    Birth Date:
    Home #:
    Health Card #:
    Cell #:
    Emergency Contact Name:
    Phone #:
    Family Doctor:
    Phone #:
    Referred by:
    Phone #:
    Email Address:


    Method of payment:
    Insurance Holders Information:
    Name of Primary Ins. holder:
    Birth Date:
    Insurance Company:
    Policy/Contact #:
    Certificate ID#:
    Name of Secondary Ins. holder:
    Birth Date:
    Insurance Company:
    Policy/Contact #:
    Certificate ID#:


    What is the reason for your visit today?
    How frequent do you see a dentist?
    Date of last dental visit?
    Date of last x-rays?
    How many times a day do you Brush?
    Are your teeth sensitive to?
    Do your gums bleed when?
    Are you satisfied with your teeth?
    Do your gums feel swollen or tender?
    Do you have bad breath or a bad taste in your mouth?
    Does your jaw crack/pop/grate when opening wide?
    Does food get trapped between your teeth?
    Do you clench or grind your teeth?
    Have you had local anesthetic?
    Have you had complications from it?
    Have you had complications from dental work?
    Have you ever had any of the following?


    Are you under the care of a physician?
    Have you ever been hospitalized?
    Are you on any medications?
    Medication List:
    Are you currently taking Anticoagulants (e.g. Coumadin)?
    Have you had an adverse reaction to any of the following?
    Have you been told to avoid any medications?

    Ever taken prolonged medical/non-medical drugs?

    Do you have any allergies? (i.e. latex, mint, anesthetics etc.)

    Do you bruise easily or have prolonged bleeding?
    Have you ever fainted, had shortness of breath or chest pain?

    Do you smoke tobacco products?

    Do you use a vape?

    Do you use cannabis products?

    Are you pregnant?
    Use birth control?
    Reached menopause?
    Do you currently have, or have ever had any of the following?
    Please check all that apply:
    CHILDREN: Have they had any of the following? Include Approximate dates.

    General Release: I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that the information I have provided is correct and haven’t knowingly omitted data. I consent to the release of the medial information from my medical doctor or health care provider as is required by this office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment.