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    642 Upper James Street, Hamilton, Ontario. L9C 2Z2

    Phone: +1-905-574-9617 Fax: +1-905-574-9691

    Email: info@thedentalplace.co   Website:  www.thedentalplace.co

  • New Patient and Medical History Form

    Your cooperation in completing this questionnaire is essential in order to provide you with dental care in a safe and efficient manner. All information is protected by the patient - doctor confidentiality.

  • Registration Information

  • The patient is an*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • How did you find out about our office?*

  • Insurance

    Please be advised that dental insurance or benefits is a contract between you, your employer and your insurance provider and any available benefits are determined by your individual policy. Under the Privacy Act, the majority of insurance providers will not provide our office with specific details regarding your coverage. We cannot influence how much of our fees your insurance will cover. Our objective as dental health care providers is to diagnose and recommend treatment according to each patient’s particular needs. We do not know if your insurance will cover the treatment we propose, as this is only outlined in your policy handbook. If you need assistance with the handbook, we can help.

  • Do you have dental insurance:*
  •  - -

  • Emergency and MD

    In case of emergency, we should notify

  • Format: (000) 000-0000.

  • Medical History

  • Are you currently being treated for any medical condition or have you been treated within the past year?*
  • Do you have unresolved health issues?*
  • Has there been any change in your general health in the past year?*
  • Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
  • Have you ever been advised to take premedication before dental treatment?*
  • Do you have any allergies to medications, latex/rubber products and any other?*
  • Do you have a prosthetic or artificial joint?*
  • Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?*
  • Do you have a bleeding problem or bleeding disorder?*
  • Do you take baby aspirin or other blood thinners on a regular basis?*
  • Have you ever been hospitalized for any illnesses or operations?*
  • Do you have or have you ever had any of the following?
  • Are there any conditions or diseases not listed above that you have or have had?*
  • Are there any diseases or medical problems that run in your family?*
  • Do you smoke or chew tobacco products?*
  • For women only: Are you breastfeeding or pregnant?

  • Dental History

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  • Have you seen a dentist regularly?*
  • Do any of your teeth ache?*
  • Do have a bad taste or bad breath?*
  • Have you ever had implant surgery?*
  • Do you gums bleed when you brush or floss?*
  • Do you have any pain when you chew?*
  • Have you had any trauma to your jaw or face?*
  • Have you ever had jaw surgery?*
  • Are you nervous during dental treatment?*

  • To the best of my knowledge, the above information is correct. I consent to the dental procedures agreed to be necessary or advisable, including the use of local anesthetics and radiographs, as indicated, and I will assume responsibility for fees associated with those procedures.

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