Medical History Form

About You – The Patient

Emergency Contact

If Minor

Medical History

Have you ever had any of the following diseases or medical problems?

Dental History

I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.
Our office respects and exceeds infection control standards mandated by the Canadian Dental Association and the Canadian Association of Orthodontists.