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Personal Information

Today's Date:
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:

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: