General Medical History Form

Patient Medical History Form

Name:

Preferred Name/Nickname:

Date of Birth:

Address:

City:

PC:

Email:

Main Phone:

Cell Phone:

Work Phone:

Employer:

Occupation:

Emergency Contact:

Contacts Number:

Preferred Method(s) of contact:

Phone

Text

Medical Physician:

Physicians Number:

Last Seen?:

Medical Specialist:

Specialists Number:

Last Seen?:

Referred by:

Please Specify:

Do you have Dental Insurance Benefits?

Yes

If yes, please provide your benefits card to us.

Dental History *

1. Have you ever had a negative dental experience?

2. Have you ever had complications following dental treatment?

3. Do you have trouble getting numb with local anesthetics?

4. Do you have sore or bleeding gums?

5. Do you experience tooth sensitivity?

6. Have you had teeth removed before?

7. When was your last visit to a dental office?

Reason?

8. When were your last xrays taken?

9. What is the reason for your visit today?

List any other conditions not mentioned above:

Please explain any 'Yes' answers:

Please list any medications including prescriptions, over-the-counter, and natural health products:

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.

Signature:

Date:

Patient Validation:

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