Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATIONPlease fill out as accurately as possible.Name *Date of Birth (D/M/Y) *Legal guardian/Parent (if child) *Gender: *MaleFemaleAddress *City *Postal Code *Home PhoneCell PhoneWork PhoneEmail *EMERGENCY INFORMATIONEmergency Contact *Relationship to Patient *Emergency Phone *Name of Family DoctorAddress of ClinicPhoneReferred byFamilyFriendFlyerGoogle/WebsiteFacebook NewspaperBest method of contact *EmailHome PhoneWork PhoneCell PhoneText MessageBest Time to Call *Any timeMorningAfternoonEveningNightINSURANCE INFORMATIONName of InsuredRelationship to PatientInsured Date of Birth (D/M/Y)Name of EmployerInsurance CompanyPolicy/ Plan/ Group #Subscriber ID #Do you have any additional insurance? *YesNoIf yes, complete the following.Name of InsuredRelationship to PatientInsured Date of Birth (D/M/Y)Name of EmployerInsurance CompanyPolicy/ Plan/ Group #Subscriber ID #MEDICAL HISTORYThe following information is required to accurately diagnose any condition and to give the highest possible standard of professional services.Do you have or have you had any of the following diseases or problems? PLEASE MARKFainting spells or seizures: eg. Epilepsy *YesNoDiabetes *YesNoDiabetes TypeKidney Disease *YesNoBlood disorders/Anemia/Problem Clotting *YesNoSteroid/Cortisone therapy *YesNoOrgan transplant or medical implant *YesNoTuberculosis *YesNoHIV infection or AIDS *YesNoThyroid disease *YesNoHepatitis (A, B, C), jaundice or liver disease *YesNoHeart murmur or mitral valve prolapse *YesNoHigh/low blood pressure, cholesterol *YesNoStroke/ Heart attack *YesNoMental or Nervous Disorder *YesNoRheumatic Fever, Scarlet Fever, Joint Replacements *YesNoArthritis or Rheumatism *YesNoCongenital Heart Lesions/Heart Murmur *YesNoCancer (Tumors/Growths)/Chemotherapy *YesNoLung disease or breathing disorder, asthma, hay fever *YesNoAre you pregnant or breastfeeding? *YesNoStomach/Intestinal problems/Ulcers *YesNoDo you Smoke? *YesNo# per dayDrug or alcohol dependency *YesNoDo you have a history of sleep apnea? *YesNoALLERGIES (e.g. medications, latex, other)MEDICATION PRESENTLY TAKING: (Please include over-the-counter medications and herbal supplements)DrugForDrugForDrugForDrugForNotes & Other InformationHave you been in the hospital for a serious illness or had an operation in the past? *YesNoAre there any diseases or medical conditions that run in your family? (e.g. diabetes, cancer or heart disease) *YesNoDiseases or medical condition NameDENTAL HISTORYDate of Last Dental Visit (D/M/Y)Reason for Last VisitDate of Last Dental X-rays (D/M/Y)Reason for Visit TodayCheckupCleaningEmergencyConsultDo you experience any of the following?Sensitivity to hot/cold/sweetsBroken fillingsBroken teethLoose TeethCavity/Tooth DecayBad BreathBleeding gumsGum recessionJaw pain/migrainesGrinding teethDo you feel nervous about having dental treatment? *YesNoHave you had any previous bad experiences at a dental office? *YesNoPatient CertificationI hereby certify that this medical and dental history is accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic or any drugs as indicated. I also consent to the collection, use and disclosure of my, my child’s, or my ward’s personal information as set out in the Personal Information Consent Form which I have read.Patient (Parent, Guardian) Name *Patient (Parent, Guardian) Signature *Clear SignatureDate *EmailSubmitCall or Email to book an appointment today! Our Services 416-299-1020 Appointment Booking Hours Mon: Closed Tues-Thurs: 10am – 7pm Fri-Sun: 9am – 5pm 1001 Sandhurst Circle, Unit 207 Scarborough, ON M1V1Z6 Book Appointment