We are open for all dental procedures, both emergency and elective. To view our extensive safety procedures and what to expect at your dental appointment, please review our guidelines.
COVID-19 Guidelines
Welcome to Dr. Salim Kapadia Dental
416-321-3268
1825 Markham Rd. Suite 102
info@drsalimkapadiadental.com
Home
About
About Us
Meet The Team
Testimonials
Services
General Dentistry
Patient Safety
Dental Fillings
Root Canals
Extractions
Scaling & Root Planing
Dentures
Intraoral Camera
Pan, Ceph & Digital X-ray
Night guard
Sports Mouth Guard
Snoring Appliances
Pediatric Dentistry
Cosmetic Dentistry
Laser Teeth Whitening
Dental Veneers
Dental Crowns
Dental Bridges
Dental Bonding
Smile Makeover
Dental Implants
Single tooth Dental Implant
Multiple Teeth Dental Implant
Implant Retained Dentures
Dental Implants vs Traditional Bridge
Forms
New Patient Form
Post Op Minor Surgery Instructions
Patient Acknowledgement Form
Patient Screening Form
Blog
Patient Education
Contact
Appointments
COVID-19
Patient Screening Form
How to Handrub
How to Handwash
Cover Your Cough
Staff Daily Screening Form
Return to Work Screening Form
Before Entering Clinic
Home
About
About Us
Meet The Team
Testimonials
Services
General Dentistry
Patient Safety
Dental Fillings
Root Canals
Extractions
Scaling & Root Planing
Dentures
Intraoral Camera
Pan, Ceph & Digital X-ray
Night guard
Sports Mouth Guard
Snoring Appliances
Pediatric Dentistry
Cosmetic Dentistry
Laser Teeth Whitening
Dental Veneers
Dental Crowns
Dental Bridges
Dental Bonding
Smile Makeover
Dental Implants
Single tooth Dental Implant
Multiple Teeth Dental Implant
Implant Retained Dentures
Dental Implants vs Traditional Bridge
Forms
New Patient Form
Post Op Minor Surgery Instructions
Patient Acknowledgement Form
Patient Screening Form
Blog
Patient Education
Contact
Appointments
COVID-19
Patient Screening Form
How to Handrub
How to Handwash
Cover Your Cough
Staff Daily Screening Form
Return to Work Screening Form
Before Entering Clinic
New Patient Form
Home
/
New Patient Form
Personal Information
Today's Date:
Initial:
DR
MR
MRS
MS
MISS
Date of Birth:
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Dental Insurance:
No
Yes
Primary Insurance
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Insurance Card Front:
Insurance Card Back:
Secondary Insurance
Date of Birth:
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Insurance Card Front:
Insurance Card Back:
Medical History
1. Are you in good health?
Yes
No
2. Are you being treated by a physician for any illness or condition?
No
Yes
3. Have you had any serious illness/operation/hospitalized?
No
Yes
4. Please Specify and list all current medications:
Have you taken any long term medications in the past? Prescription or Non-Prescription
No
Yes
5. Do you have any allergic reaction to any medications? e.g. Penicillin, Codeine, Aspirin
No
Yes
6. Is there any family history of any illness/disease, e.g. heart problems, diabetes, cancer
No
Yes
7. Have you had any injuries to your face or jaw?
No
Yes
8. Do you bleed or busied easily/prolonged bleeding?
No
Yes
9. Have you had any contact with the AIDS/HIV virus?
No
Yes
10. Have you had any reactions to local freezing?
No
Yes
11. Women: Are you pregnant?
No
Yes
12. Have you been warned against taking any medication?
No
Yes
Mark if any of the following apply to you
Arthritis
AIDS/HIV
Asthma
Blood Disorder
Cancer
Diabetes
Heart Murmur
Joint Replacements
On Birth Control Pills
Epilepsy
Heart Disease
High/Low Blood Pressure
Kidney Disease
Liver Disease
Mental/Nervous Disease
Hepatitis/Jaundice
Smoke/How much?(specify in comments at the end)
Gum Disease
Lung Disease
Thyroid Problems
Tuberculosis
Venereal Disease
Pace Maker
Rheumatic Fever
Heart Prosthesis
Have Fainted
Bad Mouth Odour
Dental History
14.When was your last dental checkup/cleaning?
Months
15. Are you happy with the appearance of your smile and teeth?
Yes
No
Have you ever had or experienced any of the following:
Bad Dental Experience
Cap/Crowns/Bridge
Root Canal
Gum Treatment
Bad Breath
Headaches
Food Lodgement
Cleaning/Scaling
Implants
Braces
Sensitive Teeth
Swollen/Painful Gums
Lock jaw
Anxiety
Fillings
Partial/Full Dentures
Extractions
Bleeding Gums
Gagging
Clenching/Grinding
Tension
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:
Parent/Guardian: