Home
About
- Our Team
  Dr. Sarna
  Dr. Kifah Alyassin
  Dr. Gurki Malhi
  Amna
  Haydee
- Haidy
  Beata
  Nosheen
  Tania
  Tracey
Services
- Dental Implants
  Orthodontics
  Oral Sedation
  Dental Bone Grafting
  Porcelain Veneers
  Teeth In a Day
  Root Canal Therapy
  Dentures
  Periodontal (Gum) Care
  Cosmetic Dentistry
- Same Day Crowns
  Botox & TMJ Treatment
  Connective Tissue Graft
  Invisalign®
  Plasma Rich Fibrin
  Sleep Apnea
  Children’s Dentistry
  Sports Mouthguards
  Wisdom Teeth
Technology
- Laser Dentistry
  Seiler Microscope
  Soft Tissue Laser
  3D Cone Beam CT Scan
  Velscope
  Water Purification System
- Digital Radiography
  Isolite Dental Isolation System
  Early Laser Cavity Detection
  The Wand
  Air Purification System
  ITero Digital Scanner
Video
Blog
Patient Forms
Contact

Home
About
Services
Technology
Video
Blog
Patient Forms
Contact

Patient Forms

Patient Forms2019-03-18T11:34:47+00:00

Patient Registration Form

Before coming in feel free to download the patient registration form OR fill out the form below.

Download Form

Dental/Medical History Form

Personal Information
Salutation
First Name*
Last Name*
Initials
Gender
- Male
- Female
Date of Birth*
Address Information
Address*
City*
Province*
Postal Code*
Contact Information
Residential Phone*
Cell Phone*
Work Phone
Email
Preffered Method of Contact
Emergency Contact Name*
Emergency Contact Phone*
Insurance Carrier
Primary Insurance
Name of Insured
Date
Employer
Insurance Provider
Group Policy #
Division
ID / Certificate #
SIN #
Secondary Insurance
Name of Insured*
Date
Employer*
Insurance Provider*
Group Policy #*
Division
ID / Certificate #
SIN #
Medical History
Are you presently under the care of a Physician?
- Yes
- No
Have you been hospitalized in the past 2 years?
Are you taking any drugs or medications? Click the + button to add a new medication.
Have you ever had any allergies to any medication?
- Yes
- No
Which Medications?
Have you ever been warned against using any medication?
- Yes
- No
Which Medications?
Do you suffer from any non-drug related allergies?
- Yes
- No
List any non-drug related allergies
Are you allergic to latex?
- Yes
- No
Do you bruise easily or have prolonged bleeding?
- Yes
- No
Do you smoke?
- Yes
- No
How many per day?
Have you ever had chest pains?
- Yes
- No
Do you have shortness of breath?
- Yes
- No
Have you ever been advised to take antibiotics before a Dental treatment?
- Yes
- No
Women
Are you pregnant?
- Yes
- No
What is the due date:
Have you reached Menopause?
- Yes
- No
Are you using Birth Control?
- Yes
- No
Children
Chicken Pox
- Yes
- No
When
Measles
- Yes
- No
When
Mumps
- Yes
- No
When
Strep throat
- Yes
- No
When
Tonsillitis
- Yes
- No
When
Do you have, or have you ever had, any of the following?
- A.I.D.S
- Anemia
- Angina
- Anorexia Nervosa
- Arthritis/Rheumatism
- Artificial Heart Valve
- Artificial joint(s)
- Asthma
- Blood disorder
- Bronchitis
- Bulimia
- Cancer
- Circulation problems
- Congenital heart lesions
- Cortisone/steroid treatment
- Diabetes
- Drug/alcohol dependence
- Emphysema
- Epilepsy/Seizures
- Glandular disorders
- Glaucoma
- Head/neck injuries
- Heart disease/Attack
- Heart murmur
- Heart pacemaker/surgery
- Heart rhythm disorder
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Herpes
- High/Low Blood pressure
- H.I.V Positive
- Hodgkin’s disease
- Hyper/Hypo Glycemia
- Hypertension
- Jaundice
- Kidney disease
- Liver disease
- Leukemia
- Lung disease
- Malignant hypothermia
- Mental/nervous disorder
- Migraine headaches
- Mitral valve prolapse
- Organ transplant/implant
- Psychiatric treatment
- Radiation/chemotherapy
- Recurring headaches
- Rheumatic or scarlet fever
- Sickle cell disease
- Sinus trouble
- Stomach/intestinal probs
- Stroke
- Thyroid disease
- Tuberculosis
- Venereal disease
Dental History
What is your reason for today's visit?
How frequently do you see a dentist?
When was your last dental visit?
Who was your dentist?
How often do you brush per day?
How often do you floss per day?
Are your teeth sensitive to
- Cold
- Sweets
- Heat
- Other
Do your gums bleed when:
- Brushing
- Flossing
- Never
Do your gums feel swollen or tender?
- Yes
- No
Do you have bad breath or a bad taste in your mouth?
- Yes
- No
Do your jaws crack, pop or grate when you open widely?
- Yes
- No
Do you experience recurring headaches or migraines?
- Yes
- No
Do you grind or clench your teeth?
- Yes
- No
Does food ever catch between your teeth?
- Yes
- No
Have you ever had local anesthetic? (freezing)
- Yes
- No
Any complications? Specify
Have you ever had any problems with previous dental treatment?
- Yes
- No
Specify
Have you ever had any of the following?
- Bridgework
- Crowns/Caps
- Full/Partial Dentures
- Orthodontic (braces)
- Periodontal (gums)
- Root Canal
Do you snore?
- Yes
- No
Any family history of Sleep apnea?
- Yes
- No
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 to the best of my knowledge and that I have not 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 authorize electronic submission of benefits claims on my behalf to my insurance carrier.Missed appointments or cancellations with less than 2 business days notice will be billed $50
Form Verification*
- I verify the information provided above is correct.