We apologize for the length of this form, we only need this filled out once. Thank you
Date of Birth*:
Spouse/Partner's Name (if applicable):
Mobile Phone (if different from main phone):
Which do you prefer to confirm your appointments?* (You may choose multiple)
Text Message (most popular)EmailVoice Call
Place of Employment:
Spouse's Place of Employment:
Do you Have Insurance*?
If Yes, Which Insurance Company:
Insurance Policy# / Plan#
How did you Hear About us*?
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*.
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*.
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*?
If Yes, Which ones, and What for?
Are you on any blood thinners*?
If Yes, Which Ones?
Do you bleed easily from a cut or injury*?
If Yes, How Long Until You Clot?
Are you a hemophiliac*?
If Yes, Which Type:
Any artificial heart valves, infective endocarditis, or any heart condition*?
If Yes, Please Clarify:
Do you have rheumatoid arthritis, lupus, or any immune-suppression*?
If Yes, Please Specify:
Are you Diabetic*?
Type 1Type 2
Last Blood Glucose Taken:
Last Blood Glucose Value:
Are you Asthmatic*?
If Yes, Please Check Severity Level:
If Yes, Last Asthma Attack:
Do you Have any Allergies*?
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?)
If Yes, Please Describe:
Have you had hip, knee, or any other joint replacement surgery*?
If Yes, Which Surgery, and When (year)?
Have you ever been advised to take antibiotics before dental treatment*?
If Yes, Why?
Have you ever had hepatitis, HIV/AIDS, or any infectious disease*?
Have you had radiation or chemotherapy*?
If Yes, When and Which Type:
Do you have epilepsy or seizures*?
If Yes, Last Episode:
Do you now, or did you used to smoke*?
If Yes, How Many Per Day, or When Did you Quit:
Do you use any Recreational Drugs*?
Are there any Other Medical Condition/Issues Not Mentioned? If so, Please Describe:
Are you Currently Taking Birth Control*?
Are you Pregnant*?
Are you Breastfeeding*?
Have you Been to the Dentist in the Last 2 Years*?
Who was your Previous Dentist?
Are you unhappy with the appearance of your teeth*?
If Yes, Please explain:
Do you have any concerns about having dental treatment*?
If Yes, Please Tell us About them:
Have you Ever had an Upsetting Experience in a Dental Office*?
If Yes, Please tell us About it:
Have you Ever had a Complication Occur in a Dental Office*?
How Often do you Brush:
How Often do you Floss:
Is there a Problem you Would like Treated Immediately*?
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
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:
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.
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).
8:00am – 7:00pm
8:00pm – 7:00pm
8:00am – 5:00pm
By Appointment Only
Coming from out of town? Follow directions to Donly Dental. Now welcoming new dental patients from Delhi and Port Dover!
Fill out this form and we'll get right back to you!