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If yes, please fill in the following insurance information. Otherwise, skip this section.
Primary Insurance Company
% Coverage For:
Secondary Insurance Company (if applicable)
Are you presently being treated by a physician?*
Have you ever been hospitalized?
Are you taking any medications, pills, drugs, or medicine?*
Do you suffer from any allergies (hay fever, latex, etc)?
Allergies: Have you ever had a reaction to any of the following?*
Have you ever been warned against using any other medications?
Have you ever taken prolonged medical or non-medical drugs?
Do you bruise easily or have prolonged bleeding?
Have you ever fainted, had shortness of breath, or chest pains?
Do you smoke?
Are you pregnant?
Are you using birth control?
Have you reached menopause?
Has your weight, appetite or energy level changed dramatically recently?
Do you follow a special diet, or are you on a diet pill therapy?
Have you or anyone in your family tested HIV positive or have Hepatitis A B C?
Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?
Have you ever had any injury or surgery to your face or jaws?
Do you wear eyeglasses or contact lenses?
Do you have any hearing difficulties?
Do you have or have you had any of the following conditions. Please check all that apply:*
CHILDREN: Have you recently had any of the following (approximate date)?
Is there anything else we should know about your health?
What is the reason for this visit? Emergency Examination Cleaning Other:
How frequently do you see your dentist? Every 3-6 months Annually Other:
Date of your last dental visit?
Date of your last X-Ray?
Are your teeth sensitive to: Cold Sweets Heat Other
Do your gums bleed when: Brushing Flossing Never
Do you have or have you had any of the following conditions. Please check all that apply:
Are you satisfied with your teeth?
1141 Lawrence Ave W,
North York, ON