Medical History Form

PERSONAL INFORMATION:

First Name

Last Name

Date of Birth (DD/MM/YY)

Family Physician:

Physician Phone

Office Name

The following information is required to enable us to provide you with the best possible dental care. All information is strictly confidential.

MEDICAL HISTORY:

Are you being treated for any medical conditions at the present time or within the last year

List all medications, non-prescription drugs or herbal supplements taken within the last two years

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Have you ever had an allergic reaction to any of the following:

Other:

if other please specify:

DO YOU HAVE OR HAVE YOU EVER HAD:

Other Diseases or Conditions (If Not Listed)

Have you been advised to take pre-medication for dental appointment?

Are You Currently Pregnant? (If yes, how many weeks are you?)

PATIENT CERTIFICATION AND CONSENT

I, the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics. I will assume full responsibility for associated fees with these procedures. I consent to the electronic sharing of information with my insurance company for the purposes of processing insurance claims and the determination of benefits. I authorize the dentist to treat me and I assume fully responsibility for the fees at the time of the appointment. I am aware that if for any reason the insurance company does not pay the full amount for treatment rendered, I am responsible for the balance.

INITIALS ( PARENT OR GUARDIAN IF UNDER 18)

DATE (DD/MM/YY)

PHIA permits us to collect and use your personal health information. PHIA also allows us to share it with others both inside and outside our organization. We do this for purposes such as:

- To provide you with health care;
- To get payment for your care which could include private insurers;
- To do health system planning and research;
- To report as required by law

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