* marked are required field.

    Personal Information

    Today's Date *:

    Initial *:

    Date of Birth *:

    Dental Insurance *:

    Primary Insurance

    Date of Birth *:

    Insurance Card Front:
    Insurance Card Back:

    Secondary Insurance

    Date of Birth:

    Insurance Card Front:
    Insurance Card Back:

    Whom should we thank for referring you to our dental office? *

    Medical History

    1. Are you in good health? *

    2. Are you being treated by a physician for any illness or condition? *

    3. Have you had any serious illness/operation/hospitalized? *

    4. Please Specify and list all current medications:

    Have you taken any long term medications in the past? Prescription or Non-Prescription *

    5. Do you have any allergic reaction to any medications? e.g. Penicillin, Codeine, Aspirin *

    6. Is there any family history of any illness/disease, e.g. heart problems, diabetes, cancer *

    7. Have you had any injuries to your face or jaw? *

    8. Do you bleed or busied easily/prolonged bleeding? *

    9. Have you had any contact with the AIDS/HIV virus? *

    10. Have you had any reactions to local freezing? *

    11. Women: Are you pregnant? *

    12. Have you been warned against taking any medication? *

    Mark if any of the following apply to you

    ArthritisAIDS/HIVAsthmaBlood DisorderCancerDiabetesHeart MurmurJoint ReplacementsOn Birth Control Pills
    EpilepsyHeart DiseaseHigh/Low Blood PressureKidney DiseaseLiver DiseaseMental/Nervous DiseaseHepatitis/JaundiceSmoke/How much?(specify in comments at the end)Gum Disease
    Lung DiseaseThyroid ProblemsTuberculosisVenereal DiseasePace MakerRheumatic FeverHeart ProsthesisHave FaintedBad Mouth Odour

    Dental History

    14. When was your last dental checkup/cleaning? *

    15. Are you happy with the appearance of your smile and teeth? *

    Have you ever had or experienced any of the following:

    Bad Dental ExperienceCap/Crowns/BridgeRoot CanalGum TreatmentBad BreathHeadachesFood Lodgement
    Cleaning/ScalingImplantsBracesSensitive TeethSwollen/Painful GumsLock jawAnxiety
    FillingsPartial/Full DenturesExtractionsBleeding GumsGaggingClenching/GrindingTension

    I, understand, certify that I have provided an accurate and complete personal & medical-dental history & have knowing not omitted any information. I have the opportunity to ask & receive answers regarding my medical-dental history. I authorize the dentist to perform/diagnosis procedures & treatment as may be necessary for proper dental care. I also understand that consultation with a medical doctor may be required, & consent to my physician being contacted if requires. I understand that responsibility for all payments for dental services for myself/dependants is mine, & I will assume responsibility for fees associated with these services. By signing below, I am knowingly, authorizing the assignment of benefits from my primary & (if applicable) secondary benefits coverage to Dr. Salim Kapadia's Dental Centre.

    Patient's Signature *: