755 McGill Rd, Ste 206
Mon-Fri: 8:00 AM–4:00 PM
Emergency Contact/Guardian Information (if patient is under 18)
Please Provide Us With Your Dental Insurance Information for Your Reimbursement
Has there been any changes in your health within the past year?
Are you now under the care of a physician?
Do you have, or have you ever had, any of the following? Check if YES
Are you presently taking or have you recently taken any of the following? Check if YES
Current medications (please list all prescription and non-prescription medications—ask your pharmacy for a print if unsure)
Are you currently taking any suppliments, specifically ginko, garlic, or ginseng?
Have you ever had an allergic reaction to any drugs/medications or foods, specifically nuts or eggs?
Have you ever had any serious illnesses, operations, or hospitalizations that as yet have not been mentioned?
Have you ever had a general anaesthetic (put to sleep?) for a procedure?
Do you have any other medical conditions that are not listed on this form?
Do you drink alcohol?
Do you smoke?
Are you pregnant, or is there a chance you may be?
Are you Nursing
Are you currently on birth control?