Harbourfront Dental

Medical History Form

10 Lower Spadina Avenue, Suite 202, Toronto, ON, M5V 2Z2      416-260-2001

The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Patient Contact Information

Patient's Name:
Patient's D.O.B.

Home Phone #:
Cell #:
Address (Inc. Apt # if applicable):
Postal Code:
Person responsible for account: Self / Other
Do you have a dental plan?

Insurance Company:
Group Policy/Plan Number:
Certificate / ID #:
Family Physician:
Phone Number:
In case of an emergency please notify:

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. Please fill in the entire form.

YesNo YesNo
Are you in good health? Do you bleed or bruise easily?
Have you ever had a heart murmur, mitral valve prolapse or rheumatic Fever Have you ever been advised by your doctor to take antibiotics before dental treatment?
Have you ever been exposed to Hepatitis or Jaundice? Women only: Are you pregnant or breast-feeding?
Has there been any change in your general health in the past year?

If yes, explain
Are you currently taking any medication, non-prescription drugs or herbal supplements of any kind?

If yes, please specify
Do you have any allergies? (e.g. penicillin, latex/rubber product)

If yes, please specify
Do you have a heart problem of any kind?

If yes, please explain
Have you ever been hospitalized for any illness or operations?

If yes, please explain
Do you smoke cigarettes?

If yes, how many?
Do you drink alcohol?

If yes, how much and how often?
Do you do recreational drugs?

If yes, please explain?

Do you have or have you ever had any of the following? Please check those that apply.

YesNo YesNo
HIV Hepatitis A
Hepatitis B Hepatitis C
AIDS Dizziness
Anemia Epilepsy
Arthritis/Rheumatism Excessive bleeding
Asthma Fainting
Blood Disease Hay Fever
Cancer Head Injuries
Diabetes High/Low Blood Pressure
Hip Replacement Surgery Stomach Ulcer
Knee Replacement Stroke
Kidney Disease Thyroid Problem
Liver Disease Tuberculosis
Lung Disease Venereal Disease
Mental Disorder Prosthetic Heart Valve
Have you ever had any illness not included above?

If yes, please specify

Reason for today's visit:

Examination and Cleaning?
Emergency or Specific Problem?

Office Policy (Please Read)

We will help prepare insurance claim forms and assist in requesting reimbursements from insurance companies on behalf of our patients. Not all services may be covered by dental insurance and every plan has its own unique quirks and exceptions. We will do our best to help you clarify your plan. However, it is the patient’s responsibility to understand his or her own dental insurance benefits. Unless otherwise agreed upon, services are to paid for at each visit as they are performed.

Please help us in providing the very best of service by remembering that once you have made an appointment this time is reserved for you. Therefore, we require a minimum of 48 hours notice (2 business days) if an appointment must be cancelled or rescheduled. A fee may be charged for cancelled or missed appointments without sufficient notice. Please note that insurance companies do not cover fees for broken appointments. Therefore such fees are the patient’s responsibility.