Patient Medical History Form
Main Phone:
Emergency Contact:
Preferred Method(s) of contact:
Referred by:
Do you have Dental Insurance Benefits?

Dental History *

Health History *
Have you experienced an allergic reaction to any of the following: *

Patient Consent *

This is to certify that I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable. I understand that the use of local anaesthetics is commonly required for dental procedures and that there are some possible risks associated with any injection including but not limited to: traumatic injuries and soreness from the injection, rapid heartbeat, temporary or permanent injury to nerves.

I am responsible for the fees associated with my treatment, and I agree to pay for any amounts not covered by my dental benefits plan.