BurlingtonDental.net

Name

First Name.

Last Name.

Email *

Phone *

Address * Street Adress

City

Province

Postal Code

Gender *

Are you a minor? (under the age of 18)

Date of Birth

Employer Name (if any)

If available, please confirm this date and time to visit Burlington Dental.*

Time *

How did you hear about us? *

Medical Health History

Family Physician

Physician Address Street Address

City

Province

Postal Code

Physician Phone

Are you under the care of a Medical Specialist?

Yes

Emergency Contact's Name In case of emergency, please contact this person.

First

Last

Emergency Contact's Phone

Do you have or have you had any of the following? (Please check any that apply)

Do you smoke or use chewing tobacco?

Yes

Are you allergic to, or have you reacted adversely to any of the following?

Latex materials
Local anesthetic
Food

Penicillin or other antibiotics
Metal
Other

Do you have any disease, condition, or problem not listed above that you are being treated for?

Have you ever been advised to take antibiotics before dental treatment?

Yes

Any change in your general health in the past year?

Yes

Are you presently taking any Prescription or NON Prescription drugs?

Yes

Additional Info Please add anything else you would like us to know about:

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Patient Declaration

I, the undersigned, certify that I have provided an accurate and complete personal, medical history and have not knowingly omitted any information. Should there be any changes in either my health or any other information I have provided, I will advise this dental hygiene office. I authorize the dental hygienist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within guidelines of the policy. I understand that responsibility for payment of the dental hygiene services for myself and my dependents is mine, and I assume responsibility for fees associated with these services.

*The Submit button will appear after certify that the information above is accurate.

Yes, I certify that the information above is true.*

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Patient Information

Medical Health History