1295 Riverbend Road Suite 260
Do you have dental insurance?
If YES, complete the following
Has there been any change in your general health?
Are you being treated for any medical condition or have you been treated within the past 2 years?
Are you currently being treated by a physician for a specific condition?
Are you currently taking any medication?
Do you bleed or bruise easily?
Have you ever been hospitalized?
Have you ever received general anesthesia?
Have you ever had an adverse reaction to local anesthetic?
Do you have any allergies to medications?
Do you have any other allergies?
Do you currently have any of the following conditions?
Herpes / Cold Sore
Diabeter Type 1 / Type 2
Surgery to Head and Neck
Is there anything else the doctor needs to know regarding your medical health?
Do you smoke?
Are you or could you be pregnant?
Are you currently breast-feeding?
Are you currently experiencing any pain or discomfort?
Are any of your teeth sensitive to
Do you have difficulty chewing food or does food get stuck between your teeth?
Are you unhappy with the overall appearance of your teeth?
Have you had braces for straightening your face?
Have you ever had an injury to your jaw or face?
Does your jaw ever click or pop or cause pain upon opening or closing?
Are you nervous during dental treatment?
PATIENT CERTIFICATION AND CONSENT
I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.
SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)
To be signed at your appointment
1295 Riverbend Road Suite 260 London, Ontario
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