October 19, 2023 Sanjith Shankar Dental Care for Busy Lifestyles: Tips from Sandhurst Family Dental Clinic Read More
October 19, 2023 Sanjith Shankar Dental Care for Busy Lifestyles: Tips from Sandhurst Family Dental Clinic Read More
New Patient Form Brighten Your Smile & Your Day at Sandhurst Family Dental Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PERSONAL INFORMATION Please fill out as accurately as possible. Name *Date of Birth (D/M/Y) *Legal guardian/Parent (if child) *Gender *Select GenderMaleFemaleAddress *City *Postal Code *Home PhoneCell PhoneWork PhoneEmail *EMERGENCY INFORMATIONEmergency Contact *Relationship to Patient *Emergency Phone *Name of Family DoctorAddress of ClinicPhoneReferred byReferred byFamilyFriendFlyerGoogle/WebsiteFacebookNewspaperBest method of contactBest method of contactEmailHome PhoneWork PhoneCell PhoneText MessageBest time to callBest time to callAny timeMorningAfternoonCell EveningNightINSURANCE 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? *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 HISTORY The 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 *Fainting spells or seizures: eg. EpilepsyYesNoDiabetes *DiabetesYesNoDiabetes TypeKidney Disease *Kidney DiseaseYesNoBlood disorders/Anemia/Problem Clotting *Blood disorders/Anemia/Problem ClottingYesNoSteroid/Cortisone therapy *Steroid/Cortisone therapyYesNoOrgan transplant or medical implant *Organ transplant or medical implantYesNoTuberculosis *TuberculosisYesNoHIV infection or AIDS *HIV infection or AIDSYesNoThyroid disease *Thyroid diseaseYesNoHepatitis (A, B, C), jaundice or liver disease *Hepatitis (A, B, C), jaundice or liver diseaseYesNoHeart murmur or mitral valve prolapse *Heart murmur or mitral valve prolapseYesNoHigh/low blood pressure, cholesterol *High/low blood pressure, cholesterol YesNoStroke/ Heart attack *Stroke/ Heart attackYesNoMental or Nervous Disorder *Mental or Nervous DisorderYesNoRheumatic Fever, Scarlet Fever, Joint Replacements *Rheumatic Fever, Scarlet Fever, Joint ReplacementsYesNoArthritis or Rheumatism *Arthritis or RheumatismYesNoCongenital Heart Lesions/Heart Murmur *Congenital Heart Lesions/Heart MurmurYesNoCancer (Tumors/Growths)/Chemotherapy *Cancer (Tumors/Growths)/ChemotherapyYesNoLung disease or breathing disorder, asthma, hay fever *Lung disease or breathing disorder, asthma, hay feverYesNoAre you pregnant or breastfeeding? *Are you pregnant or breastfeeding?YesNoStomach/Intestinal problems/Ulcers *Stomach/Intestinal problems/UlcersYesNoDo you Smoke? *Do you Smoke?YesNo# per dayDrug or alcohol dependency *Drug or alcohol dependencyYesNoDo you have a history of sleep apnea? *Do 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? *Have 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) *Are 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)Do you feel nervous about having dental treatment? *Do you feel nervous about having dental treatment?YesNoHave you had any previous bad experiences at a dental office? *Have you had any previous bad experiences at a dental office?YesNoReason for Visit TodayCheckupCleaningEmergencyConsultDo you experience any of the following?Sensitivity to hot/cold/sweetsBroken fillingsBroken teethLoose TeethCavity/Tooth DecayBad BreathBleeding gumsGum recessionJaw pain/migrainesGrinding teethPatient Certification I 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 Signature Date *NameSubmit Address 1001 Sandhurst Circle, Unit 207, Scarborough, ON M1V 1Z6 E-Mail info@sandhurstfamilydental.com Phone 416-299-1020 Working Hours Monday Closed Tuesday 10am – 7pm Wednesday 10am – 7pm Thursday 10am – 7pm Friday 9am – 5pm Saturday 9am – 5pm Sunday 9am – 5pm blog & news The Gold Standard: Read Our Recent News October 19, 2023 Sanjith Shankar Dental Care for Busy Lifestyles: Tips from Sandhurst Family Dental Clinic Published in October 2023. In the hustle and bustle of today's fast-paced world, maintaining good oral hygiene can sometimes take a back... Read More September 6, 2023 Sanjith Shankar The Vital Connection: How Oral Health Impacts Your Overall Well-being Published in September 2023. Your oral health isn't just about having a radiant smile; it's intricately linked to your overall well-bein... Read More August 28, 2023 Sanjith Shankar Start the School Year Right: Why a Visit to Sandhurst Family Dental Clinic is Essential Published in August 2023. Start the School Year Right: Why a Visit to Sandhurst Family Dental Clinic is Essential As summer winds dow... Read More July 3, 2023 Sanjith Shankar Summer Sports and Dental Safety: Tips from Scarborough Family Dentist, Dr. Pavithra Published in July 2023. Summer Sports and Dental Safety: Tips from Scarborough Family Dentist, Dr. Pavithra As the sunny days of summer... Read More June 3, 2023 Sanjith Shankar Understanding and Managing Tooth Sensitivity: Tips from Sandhurst Family Dental Clinic Published in June 2023. Understanding and Managing Tooth Sensitivity: Tips from Sandhurst Family Dental Clinic Tooth sensitivity is a c... Read More May 15, 2023 Sanjith Shankar Dental Emergency Preparedness: What Torontonians Need to Know - Expert Advice from Sandhurst Family Dental Clinic Published in May 2023. Dental Emergency Preparedness: What Torontonians Need to Know - Expert Advice from Sandhurst Family Dental Clin... Read More April 10, 2023 Sanjith Shankar Celebrating Oral Health Month in Canada with Sandhurst Family Dental Clinic Published in April 2023. Celebrating Oral Health Month in Canada with Sandhurst Family Dental Clinic April is Oral Health Month in Can... Read More March 17, 2023 Sanjith Shankar Why Regular Dental Checkups are Essential for Your Oral Health Published in March 2023. Why Regular Dental Checkups are Essential for Your Oral Health As a Scarborough family dentist, Dr. Pavithra ... Read More February 25, 2023 Sanjith Shankar Everything You Need to Know About Getting Your Wisdom Teeth Removed Published in February 2023. Everything You Need to Know About Getting Your Wisdom Teeth Removed Removing your wisdom teeth is a big de... Read More
October 19, 2023 Sanjith Shankar Dental Care for Busy Lifestyles: Tips from Sandhurst Family Dental Clinic Published in October 2023. In the hustle and bustle of today's fast-paced world, maintaining good oral hygiene can sometimes take a back... Read More
September 6, 2023 Sanjith Shankar The Vital Connection: How Oral Health Impacts Your Overall Well-being Published in September 2023. Your oral health isn't just about having a radiant smile; it's intricately linked to your overall well-bein... Read More
August 28, 2023 Sanjith Shankar Start the School Year Right: Why a Visit to Sandhurst Family Dental Clinic is Essential Published in August 2023. Start the School Year Right: Why a Visit to Sandhurst Family Dental Clinic is Essential As summer winds dow... Read More
July 3, 2023 Sanjith Shankar Summer Sports and Dental Safety: Tips from Scarborough Family Dentist, Dr. Pavithra Published in July 2023. Summer Sports and Dental Safety: Tips from Scarborough Family Dentist, Dr. Pavithra As the sunny days of summer... Read More
June 3, 2023 Sanjith Shankar Understanding and Managing Tooth Sensitivity: Tips from Sandhurst Family Dental Clinic Published in June 2023. Understanding and Managing Tooth Sensitivity: Tips from Sandhurst Family Dental Clinic Tooth sensitivity is a c... Read More
May 15, 2023 Sanjith Shankar Dental Emergency Preparedness: What Torontonians Need to Know - Expert Advice from Sandhurst Family Dental Clinic Published in May 2023. Dental Emergency Preparedness: What Torontonians Need to Know - Expert Advice from Sandhurst Family Dental Clin... Read More
April 10, 2023 Sanjith Shankar Celebrating Oral Health Month in Canada with Sandhurst Family Dental Clinic Published in April 2023. Celebrating Oral Health Month in Canada with Sandhurst Family Dental Clinic April is Oral Health Month in Can... Read More
March 17, 2023 Sanjith Shankar Why Regular Dental Checkups are Essential for Your Oral Health Published in March 2023. Why Regular Dental Checkups are Essential for Your Oral Health As a Scarborough family dentist, Dr. Pavithra ... Read More
February 25, 2023 Sanjith Shankar Everything You Need to Know About Getting Your Wisdom Teeth Removed Published in February 2023. Everything You Need to Know About Getting Your Wisdom Teeth Removed Removing your wisdom teeth is a big de... Read More