• 900 Peter Robertson Blvd #12, Brampton, ON L6R 1A2

New Patient Form

Downlaod PDF Form

We welcome you to our practice. Please fill this form to the best of your knowledge. If you have any question feel free to contact us and we'll be happy to assist you. We are delighted to help you maintain your dental health!

Patient Information

Notify in case of emergency


Medical History

Are you currently under medical care ?
Have you ever had serious illnesses or surgeries in the past?
Have you ever taken Fen-Phen / Redux?
Have you ever had a blood transfusion?
Have you ever used a bisphosphonate?
(Bisphosphonates are a class of drugs that prevent the loss of bone density, used to treat osteoporosis and similar diseases. They are the most commonly prescribed drugs used to treat osteoporsis.) *Copied from google*
Females: Are you pregnant?
Females: Are you nursing?
Females: Are you on birth control pills?
Have you ever had any of these conditions (Check)









































Dental History

What would you like done today?
Do you have a dental pain?
Former Dentist
Name
Email
Phone
Address
Date of last dental care
Date of last X-ray
Have you ever had any of these conditions (Check all that apply)














How regularly do you brush your teeth? Quantity please?
How do you feel about your teeth?
Have you ever had an adverse reaction related to a medical/dental procedure?
Other pertinent information about your dental health:


Authorization
I have reviewed the information in this questionnaire. To the best of my knowledge, this information is accurate. I understand that this information can be used by my dentist to determine appropriate and healthful dental treatments. I understand that i have to declare any change in my medical status.

I authorize the insurance company to pay the dentist all insurance benefits otherwise payble to me for serviceds rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that i an financially responsible for all charges whether or not paid by my insurance.

Signature
Date



Payment is due in full at time of treatment, unless prior arrangements have been approved.

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