Personal Information Details

Please Choose:
MrMrsMissMsDr

Your Name:

Your Email:

Address:

Date of Birth:

Current Age:

Marital Status:
MarriedSingleCommon-LawDivorcedOther

Spouse's Name (if applicable):

Main Phone:

Mobile Phone (if different from main phone):

Work Phone:

Which do you prefer to confirm your appointments?
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, 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 AType B

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 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


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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