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?

    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:
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