We understand that your time is valuable and in order to streamline your first visit, simply complete at your convenience, prior to your appointment.
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SelfSpouseParent/GuardianNone of the Above
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Please Describe:
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Date of your last dental exam
Date of your last dental cleaning
Date of your last dental x-rays
Sensitivity (hot, cold and/or sweet)Tooth pain or discomfort while chewingHeadaches, earaches or neck painJaw joint pain (clicking/cracking)Grinding or clenching teethBleeding, swollen or irritated gumsLoose, chipped or shifting teethBad breath or bad taste in your mouthNone of the above
DenturesOrthodonticsPartial denturesPeriodontal (gum) treatmentsNone of the above
Make your teeth brighterMake your teeth straighterClose gaps between teethReplace metal fillings with natural tooth coloured fillingsRepair chipped teethReplace missing teethReplace old crowns that don’t matchHave a smile makeoverNone of the above
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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?
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.
YesNo
Chest pain, anginaRheumatic feverPacemakerSteroid therapySeizures (epilepsy)Heart attackMitral valve prolapseLung diseaseDiabetesKidney diseaseStroke, TIATuberculosisStomach ulcersThyroid diseaseShortness of breathHeart murmurCancerArthritisDrug/alcohol/cannabis use or dependencyOsteoporosis medications (e.g. Fosamax, Actonel)None of the above
Expected Due Date
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.
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