Clinton Destistry | Biological & Comprehensive Dentistry

Opening Hours: Monday-Thursday: 8:00am – 4:30pm
4310 Stage Coach Rd, Sydenham, ON K0H 2T0
Call Us: 613.376.6652
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YOUR BEST DENTAL EXPERIENCE

New Patient Medical History Form

    New Patient Form

    Patient Information




















    Financial Information



    Primary






    Secondary






    Medical History

    1. Are you presently under the care of a physician?

    2. Have you ever been hospitalized?

    3. Are you taking any drugs or medication at this time?

    4. Have you ever had any adverse effect to any of the following:

    5. Have you ever been warned against using any other medications?

    6. Have you ever taken prolonged medical or non-medical drugs?

    7. Do you suffer from any allergies (hay fever, latex etc.)?

    8. Do you bruise easily or have prolonged bleeding?

    9. Do you smoke?

    10. Have you ever fainted, had shortness of breath or chest pains?

    10a. Do you use Marijuana? If yes, how often?

    10b. Do you take weight loss medications? If yes, please list:

    11. Women

    Are you pregnant?

    Using birth control?

    Reached menopause?

    12. Do you have or have you ever had any of the following? Please select appropriate boxes.


    Children

    13. Have you recently had any of the following (approximate date):


    Dental History

    1. What is the reason for today's visit?

    2. How frequently do you see dentist?

    3. When was your last dental visit?

    4. How often do you brush per day?

    5. Are your teeth sensitive to?

    6. Do your gums bleed when:

    7. Do your gums feel swollen or tender?

    8. Do you have bad breath or a bad taste in your mouth?

    9. Do your jaws crack, pop or grate when you open widely?

    10. Do you grind or clench your teeth?

    11. Do you have food catch between your teeth?

    12. Have you ever had local anaesthetic (freezing)?


    13. Have you ever had any problems with previous dental treatments?

    14. Have you ever had any of the following:

    15. Are you satisfied with your teeth?

    General Release

    I, the undersigned, understand that the information contained in the medical and dental history is
    important to my treatment. I certify that all of the information I have completed is correct and that I
    have no knowingly omitted data. I consent to the release of medical information from my medical
    doctor or other health care provider as is required by this dental office. I authorize this dental office
    to perform diagnostic procedures as may be required to determine necessary treatment.

    I understand that if I miss an appointment or provide less than 48 hours( 2 days)notice to cancel or
    reschedule an appointment, I will be charged a cancellation fee.Please note that insurance
    companies do not cover fees for missed/canceled appointments. Therefore, it will be patient's
    responsibility to pay such fees.

    I understand that it is my responsibility to pay for dental treatment for both myself and my
    dependents. I assume all responsibility for fees associated with my dental treatment of dental
    diagnostic procedures.We will assist you in preparing insurance claim forms, along with requesting
    reimbursements from your insurance company, on your behalf. Be aware that not all services may
    be covered by your insurance company, no two plans are the same. We will work with you to help
    clarify your plan. However, it is the responsibility of the patient to understand his or her own dental
    insurance benefits. Services are to be paid for at each visit as they are performed.

    I have read and fully understand the above terms and conditions and I accept my responsibility as a
    patient at this office.