Personal Information Details We apologize for the length of this form, we only need this filled out once. Thank you Please Choose*: MrMrsMissMsDrTX Your Name*: Your Email*: Street Address*: City/Town*: Postal Code*: Date of Birth*: Current Age*: Marital Status*: MarriedSingleCommon-LawDivorcedOther Spouse/Partner's Name (if applicable): Main Phone*: Mobile Phone (if different from main phone): Work Phone: Which do you prefer to confirm your appointments?* (You may choose multiple) Text Message (most popular)EmailVoice Call Family Doctor: Pharmacy: Place of Employment: Spouse's Place of Employment: Insurance Information Do you Have Insurance*? YesNo If Yes, Which Insurance Company: Insurance Policy# / Plan# Subscriber ID# How did you Hear About us*? Office Policy Please check that you understand the following office policies of Donly Dental: 1) Your appointment times are set aside especially for you. If you are unable to keep your appointment, no charge will be issued providing you give the office 2 business days notice*. I Understand 2) Any difference in cost that your insurance does NOT cover is expected at the end of each visit. Donly Dental accepts Cash, Cheque, Debit, Visa, or MasterCard*. I Understand Medical History Your assistance in completing this form in FULL will assist in giving you the safest quality medical and dental care. Are you taking any pills or medication*? YesNo If Yes, Which ones, and What for? Are you on any blood thinners*? YesNo If Yes, Which Ones? Do you bleed easily from a cut or injury*? YesNo If Yes, How Long Until You Clot? Are you a hemophiliac*? YesNo If Yes, Which Type: Any artificial heart valves, infective endocarditis, or any heart condition*? YesNo If Yes, Please Clarify: Do you have rheumatoid arthritis, lupus, or any immune-suppression*? YesNo If Yes, Please Specify: Are you Diabetic*? YesNo Diabetes Type: Type 1Type 2 Last Blood Glucose Taken: Last Blood Glucose Value: Are you Asthmatic*? YesNo If Yes, Please Check Severity Level: MildModerateSevere If Yes, Last Asthma Attack: Do you Have any Allergies*? YesNo If Yes, Please Clarify what you are Allergic to, and what Happens when you are Exposed: Any unusual reaction to any medications or injection*? (eg. penicillin, antibiotics, Advil, codeine, dental freezing?) YesNo If Yes, Please Describe: Have you had hip, knee, or any other joint replacement surgery*? YesNo If Yes, Which Surgery, and When (year)? Have you ever been advised to take antibiotics before dental treatment*? YesNo If Yes, Why? Have you ever had hepatitis, HIV/AIDS, or any infectious disease*? YesNo If Yes, Please Specify: Have you had radiation or chemotherapy*? YesNo If Yes, When and Which Type: Do you have epilepsy or seizures*? YesNo If Yes, Last Episode: Do you now, or did you used to smoke*? YesNo If Yes, How Many Per Day, or When Did you Quit: Do you use any Recreational Drugs*? YesNo If Yes, Please Clarify: Are there any Other Medical Condition/Issues Not Mentioned? If so, Please Describe: For Women Are you Currently Taking Birth Control*? YesNo Are you Pregnant*? YesNo Are you Breastfeeding*? YesNo Dental History Have you Been to the Dentist in the Last 2 Years*? YesNo Who was your Previous Dentist? Are you unhappy with the appearance of your teeth*? YesNo If Yes, Please explain: Do you have any concerns about having dental treatment*? YesNo If Yes, Please Tell us About them: Have you Ever had an Upsetting Experience in a Dental Office*? YesNo If Yes, Please tell us About it: Have you Ever had a Complication Occur in a Dental Office*? YesNo If Yes, Please Describe: How Often do you Brush: How Often do you Floss: Is there a Problem you Would like Treated Immediately*? YesNo If Yes, Please Describe: Do you Experience any of the Following (check all that apply)? sore gums or bleeding gumspopping or clicking jawgaggingloose teethloose dentureslip bitingsensitive teethheadachesteeth grinding or clenchingbad breathcrooked teethmouth sores Covid Vaccination Status Current status of vaccination against Covid-19? 0 Doses1 Dose2 Doses3 Doses Brand of Vaccine (if multiple, please write each brand): Date of Last Covid-19 Vaccine Dose: Consent for Dental Treatment I, the undersigned, authorize the dentist to perform diagnostic procedures as maybe required to determine necessary treatment. I understand that responsibility for payment for the dental services for myself and my dependents is mine, and I assume responsibility for the fees associated with these services. I certify that I have provided an accurate and complete medical and dental history. Your Signature: Use your mouse to sign on computer, or finger on a mobile device Please make sure you've filled out all of the required fields. If you are still having trouble submitting the form, you can try a different browser. (Chrome is recommended).