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.
Do you have any of the following allergies?
Please check any of the following problems that may apply to you:
Do you have or have had any of the following?
If you could change your smile, you would...
Release of Information: I authorize South Kitchener Dentistry to release and/or obtain information and/or radiographs, when required, regarding my medical/dental history friom my physician, another dental office, insurance company.
Office Policy: Your appointment time will be reserved for you. If you are unable to keep the appointment we will require 2 days notice, otherwise it may be necessary to charge for the time lost.
Patient Release: I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I understand that responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.