* marked are required field.

    Personal Information

    Today's Date *:

    Initial *:

    Date of Birth *:


    Tip: This is not your own number

    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

    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 section

    1. Are you currently being treated for any medical condition or have you been treated within the past year? *

    2. When was your last medical checkup? *

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

    4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

    5. Do you have any allergies? *

    Please list them using the categories below:



    6. Have you ever had a peculiar or adverse reaction to any medicines or injections? *

    7. Do you have or have you ever had asthma? *

    8. Do you have or have you ever had any heart or blood pressure problems? *

    9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? *

    10. Do you have a prosthetic or artificial joint? *

    11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)? *

    12. Have you ever had hepatitis, jaundice or liver disease? *

    13. Do you have a bleeding problem or bleeding disorder? *

    14. Have you ever been hospitalized for any illnesses or operations? *

    15. Do you have or have you ever had any of the following? Mark if any of the following apply to you

    Chest Pain, AnginaArthritisAIDS/HIVAsthmaBlood DisorderCancerDiabetesHeart MurmurJoint ReplacementsOn Birth Control PillsMitral Valve ProlapseDrug/Alcohol/Cannabis use or dependency
    Heart AttackSeizures (epilepsy)Heart DiseaseHigh/Low Blood PressureShortness of BreathStomach UlcersKidney DiseaseLiver DiseaseMental/Nervous DiseaseHepatitis/JaundiceSmoke/How much?(specify in comments at the end)Steroid Therapy
    Stroke, TIALung DiseaseThyroid ProblemsTuberculosisVenereal DiseasePace MakerRheumatic FeverHeart ProsthesisHave FaintedBad Mouth OdourOsteoporosis Medications (e.g. Fosamax, Actonel)Cholesterol

    16. Are there any conditions or diseases not listed above that you have or have had? *

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

    18. Do you smoke or chew tobacco products? *

    19. Are you breastfeeding or pregnant? *

    20. Do you identify as a patient with a disability? *

    Dental History

    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 section

    1. What is the reason for your visit today? *

    2. Have you been seeing a dentist regularly? *

    3. Are you nervous during dental visits? *

    4. Have you had a bad experience or complications during dental treatment? *

    5. When was your last dental visit? *

    6. When did you last have dental x-rays? *

    7. Have you ever seen a dental specialist? *

    8. How often do you brush your teeth? How often do you floss? Do your gums bleed when you brush or floss? *

    9. Have you been told to take antibiotics before a dental appointment? *

    10. Do you feel that you have bad breath? *

    11. Are you happy with the appearance of your teeth? *

    12. Do you have any problems with your jaw (clicking, limited movement, pain)? *

    13. Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident? *

    14. 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 *:
    Required field. If patient can't sign for any reason, please put a cross in this field and sign the Guardian field.
    Parent/Guardian:

    Human Verification:


    Please make sure to click the Submit button below.