Medical History Form

Please correct the errors described below.

[Please note that this form was modeled after the form Dr. Neil Gajjar uses in his practice located in Ontario, Canada. Edits may be necessary for use in other locations, including the US.]

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have any questions, we'll be glad to help you. We look forward to working with you in maintaining your dental health.

Personal Information

Please fill in health card # or upload.
    Please upload a file

    Insurance Information

      Please upload a file
        Please upload a file

        This information is collected to verify identity and settle any account balances not covered by insurance.

        Secondary Insurance Information

          Please upload a file
            Please upload a file

            This information is collected to verify identity and settle any account balances not covered by insurance.

            Health Information

            Dental Information

            Medication

            List of medication(s) you are currently taking:

            Add another medication

            Authorization

            I, the undersigned patient, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information.

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