Your Name:*
Your Address:*
Contact Information:
If yes, please fill in the following insurance information. Otherwise, skip this section.
Primary Insurance Company
% Coverage For:
Secondary Insurance Company (if applicable)
Medical History
Are you presently being treated by a physician?*
Are you taking any medications, pills, drugs, or medicine?
Do you suffer from any allergies (hay fever, latex, etc)?
Allergies: Have you ever had a reaction to any of the following?*
Have you ever been warned against using any other medications?
Have you ever taken prolonged medical or non-medical drugs?
Do you bruise easily or have prolonged bleeding?
Have you ever fainted, had shortness of breath, or chest pains?
Do you smoke?
Are you pregnant?
Are you using birth control?
Do you have or have you had any of the following conditions. Please check all that apply:*
CHILDREN: Have you recently had any of the following (approximate date)?
Is there anything else we should know about your health?
Dental History
What is the reason for this visit? Emergency Examination Cleaning Other:
How frequently do you see your dentist? Every 3-6 months Annually Other:
Date of your last dental visit?
Date of your last X-Ray?
General Release:
NEW PATIENTS WELCOME (905) 832-5000 MAPLE DENTAL OFFICE 10083 Keele Street, Lower Level Maple, Ontario L6A 3Y8 (1 Block North of Major Mackenzie)
Sedation available for your comfort
INSURANCE CLAIMS 