Please take a moment to let us know about your medical and dental history so we may serve you in a way that takes into consideration your overall health and well-being.

Patient Name:*

Prefix First Last

Phone*

Email*

How did you hear about our office?*

Pick Your Favourite Dentist*

Within the past year, have there been any changes in your general health?*

Yes
No

If yes, explain:

What is the date (or approximate date) of your last medical exam?*

Name of medical doctor and clinic

Have you ever had complications following dental treatment?*

Yes
No

If yes, explain:

Are you currently under the care of a physician due to a specific condition?*

Yes
No

If yes, explain:

Have you been hospitalized within the last 5 years due to a surgery or illness?*

Yes
No

If yes, explain:

Do you use tobacco (smoking or chewing)?*

Yes
No

If yes, how frequently:

Do you require an antibiotic Pre-Medication prior to Dental Treatment due to a heart condition or joint replacements?*

Yes
No

If yes, how frequently:

Do you require an Anti-Anxiety Medication prior to Dental Treatment?*

Yes
No

If yes, explain:

Are you pregnant?*

Yes
No

If yes, when is your due date?

Do you have any other conditions, diseases, etc. that are not listed above that we should be aware of?

If any of the previous questions are marked, please explain:

Please indicate if you have experienced any of the following:

Do you have any other health issues or allergies that our team should be aware of?

Please list all medications and homeopathic remedies that you currently take:

What is the reason for your visit today?

When was your last visit to the dentist (if to a different office)?

Prior dentist's office or name:

How frequently do you brush your teeth?

How frequently do you floss your teeth?

Please select any of the following to indicate YES response to the question:

Do your gums bleed when you brush or floss?
Do your teeth experience sensitivity to cold or hot temperatures?
Are any of your teeth currently causing you pain?
Do you grind your teeth (either consciously or during sleep)?
Have you ever or do you have a nightguard or splint?
Are any of your teeth loose, or are you concerned about any teeth loosening?
Do you currently have any dental implants, dentures or partials?
Have you had braces?

If any of the previous questions are marked, please explain:

I hereby certify that I have read and understand the previous information and that it is true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health. I will keep the dental office updated with any changes to my health and/or medications and allergies.

Authorization

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate. Privacy of our patient’s personal information is important to us. We are committed to collecting, using, and disclosing personal information responsibly. We have established and implemented a variety of security measures to properly manage and safeguard your personal information from loss, theft, and unauthorized access.

Personal information for our purposes is; that information necessary for the provision of professional oral health care services provided to you, and information necessary to administer this dental practice. Personal information includes clinical records, x-rays, study models, photographs of your teeth, mouth, smile, face, and general health information obtained from a medical history review, insurance information, phone numbers and addresses. Clinical information, photographs and x-rays may also be used for long-term follow-up, research purposes, anonymously on our website smile gallery, as well as for education or teaching purposes.

Your personal information shall be disclosed to only those who have a need to know and specific information. Disclosed shall be restricted to only that information relevant to what the recipients need to know. Those who have a need to know include referring dentist, other dental specialists, physicians, dental laboratories, and dental insurance companies. The security and privacy of your personal information is one of our primary concerns and we have taken every precaution to protect it.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependants (if any).

I am also aware of the cancellation policy of True Dental. 48 hours notice for cancellation of appointments is required in which case no charge will be made. Short notice and no show appointments will be charged at $50.00 per half hour. Please call the office and speak with a team member to reschedule.

Signature of patient, parent, or guardian:

Signature*

Date

Relationship to patient:

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Medical and Dental History Form

Authorization

Signature of patient, parent, or guardian:

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