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Young female patinet at oral checkup at the dentist office
About

Patient Registration Form

PERSON RESPONSBILE FOR ACCOUNT:

IN CASE OF EMERGENCY, WE SHOULD NOTIFY:

The following information is required to enable us to provide you with the highest standard of care. All information is kept confidential. The doctor will review the questions and explain any that you do not understand. Please complete the entire form. If you need assistance, please notify one of our front desk team members and help will be provided.

Are you being treated for any medical condition at the present or have you been treated within the past year?
Has there been any change in your general health in the past year?
Have you had any serious illnesses?
Have you ever been hospitalized for any illness or operations?
Have you been hospitalized within the last 2 years?
Have you been out of Canada within the last 2 years?
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
Do you use any cannabis products?
Do you smoke/vape or chew tobacco products?
Do you have any allergies including medications, latex/rubber products, eggs/food etc?
Have you ever had an unexpected or adverse reaction to any medications, anesthetics or injections?
Do you have a prosthetic or artificial joint?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (e.g. infective endocarditis), or a heart condition from birth (e.g. congenital heart disease)?
Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiation therapy, chemotherapy?
Do you have or have you ever had asthma?
Have you ever had hepatitis, jaundice or liver disease?
Do you have or have you ever had any of the following? Please circle which apply:
Are you taking any anticoagulation (blood thinner) medications?
Do you have a bleeding problem or bleeding disorder?
Can you easily walk up a flight of stairs?
Are there any conditions or diseases not listed above that you have or have had?
Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease?)
Are you nervous during dental treatment?
For women only: Are you pregnant or breast feeding?
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