Medical History Form

[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

Last name:

First name:

Date of birth:

Gender:

Address:

City:

Postal code:

Occupation:

Employer:

Address:

Phone (home):

Phone (work):

Phone (mobile):

Email:

Family physician:

Phone:

Date of last exam:

Marital status:

Health card #:

Please fill in health card # or upload.

Upload health card

Add file

Please upload a file

Name of spouse, parent, or guardian:

Occupation:

Employer:

Address:

Phone (home):

Phone (work):

Emergency contact:

Relationship:

Phone number:

How did you hear about us?

Another patient

Doctor

Staff

Online/social

Magazine

Newspaper

Radio

Other:

Insurance Information

Do you have dental insurance

Yes No

Upload Insurance Card

Add file

Please upload a file

Name of insured:

Insured date of birth:

Insurance company:

Group #:

ID #:

Driver's license #:

Upload driver's license

Add file

Please upload a file

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

Secondary Insurance Information

Do you fall into another family member's dental insurance?

Yes No

Upload Insurance Card

Add file

Please upload a file

Name of insured:

Insured date of birth:

Insurance company:

Plan/contract/group #:

Certificate/ID #:

Driver's license #:

Upload driver's license

Add file

Please upload a file

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

Health Information

Do you have any other health concerns?

Dental Information

Any other dental conditions:

Reasons for today's visit:

Former dentist:

City:

Province:

Date of last dental visit:

Date of last dental x-rays:

How often do you brush?

How often do you floss?

Medication

List of medication(s) you are currently taking:

Add another medication

Pharmacy name:

City/province:

Phone:

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.

Patient / parent / guardian name:

Date

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