- My Forms at Home

PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

Medical History

1. Date of last physical exam

Additional information:

2. Is your physician monitoring a health condition or treating you now?

Yes

No

If yes, additional information:

3. Have you been hospitalized or had any serious illnesses or operations?

Yes

No

If yes, additional information:

3. Has there been any change in your general health in the past year?

Yes

No

If yes, additional information:

4. Have you had any problems with either Local or General anesthetics?

Yes

No

If yes, additional information:

5. Are you taking any medications, non-prescription drugs or herbal supplements/ vitamins?

Yes

No

If yes, additional information (please list medications or provide a medical list)

6. Do you have any allergies? If yes, please list them using the categories below.

Yes

No

A) Medications

B) Latex/Rubber products

C) Other (e.g. hay fever, seasonal/environmental, foods)

Do you have or have you had:

If yes, additional information:

7. Are there any diseases or medical issues that run in your family (e.g. diabetes, cancer or heart disease)?

Yes

No

If yes, additional information:

8. Do you smoke or chew tabacco products, vape, or use marijuana

Yes

No

If yes, additional information:

Female Patients Only

Are you breastfeeding or pregnant?

Yes

No

If pregnant, what is the expected delivery date?

Are you taking any birth control medications

Yes

No

Dental History

When was your last dental appointment and what was completed

1. Have you ever been advised to take antibiotics before dental work

Yes

No

Do you/ have you experienced

2. Have you ever had your teeth straightened

Yes

No

3. Do you wear any removable appliances

Yes

No

If yes, additional information:

Do you have/ have you had a habit of:

Thumb/ finger sucking

Lip/ cheek/ tongue chewing

Chewing pens/ pencils

Fingernail biting

4. Are you at risk for oral/ facial injuries

Yes

No

If yes, additional information:

5. Are you nervous during dental treatment?

Yes

No

6. Current home care

Brushing 1x day

Brushing 2x day

Inconsistent brushing

Flossing daily

Flossing weekly

Inconsistent flossing

Mouthwash

Other aternatives

Additional information:

To the best of my knowledge, the above information is correct:

Yes

No

Patient/Parent/Guardian Signature:

Insurance Consent

I authorize release, to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist. This authorization shall continue in effect until the undersigned revokes the same. I also, hereby assign my benefits, payable from claims submitted electronically, to Dr. Alena Yurchuk and Dr. Yury Kabak, and authorize payment directly to him/her. This authorization shall continue in effect until the undersigned revokes the same.

Patient/ Guardian:

Cancelation Policy

Please keep in mind that appointment times have been set aside specifically for you, and any changes to the schedule affect a large number of people. If you are unable to keep your scheduled appointment time for any reason, we ask for two business days' (48 hours) notice so that we can offer the time to another patient who is waiting for an appointment. Appointments that are cancelled with less than two business days' notice will incur a $50.00 cancellation fee.

Patient/ Guardian: