5734 Hazeldean Rd, Unit 4, Stittsville, ON K2S 2R1

343-545-1010

About Us
Services
Gallery
Patient Forms
Promotions
FAQ’s
Contact Us
Book Your Appointment

About Us
Services
Gallery
Patient Forms
Promotions
FAQ’s
Contact Us
Book Your Appointment

New Patient Form

"*" indicates required fields

Medical History Questionnaire for New Patients

Name * Required

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Prefer not to disclose

Address * Required

Home Phone * Required

Cell Phone * Required

Occupation

Email * Required

Who referred you to our office?

In case of emergency, we should notify

Name

Relationship

Day-time Phone * Required

Family Doctor

Family Doctor Phone * Required

(1) Name of Specialist

(1) Area of Specialty

(1) Phone

(2) Name of Specialist

(2) Area of Specialty

(2) Phone

The dental staff will review the medical form with you and answer any questions. Please fill the following questions:

Any treatment for a medical condition within the past year?

Yes

Not sure/Maybe

If yes, please explain

Last medical checkup?

Any changes to your general health in the past year?

Yes

Not sure/Maybe

If yes, please explain

List of medications, non-prescription drugs, or herbal supplements (Please include doses taken):

Please also advise if you are taking any medications for blood thinners, osteoporosis, steroids, diabetes, high blood pressure

Any allergies to following medications?

Penicillin or other antibiotics

Sulfa drugs

Aspirin/NSAIDS

Iodine/Silver

Codeine

Any allergies ie: hay fever, seasonal, foods? * Required

Any adverse reaction to medication or injections?

Yes

Not sure/Maybe

If yes, please explain

Have you ever been hospitalized for any illness or conditions?

Yes

If yes, please explain

Please check mark any of the following that apply past or present: * Required

Heart Attack

Heart surgery

Angina (Chest Pain)

High blood pressure

Low blood pressure

Fainting/dizziness

Infective Endocarditis

Rheumatic fever

Prolapsed mitral valve

Artificial heart valves

Heart murmur

Congenital heart lesions

Cardiac pacemaker

Stroke

Easy Bruising

Excessive Bleeding

Anemia

Haemophilia

Von Willebrand

Hives, skin rash

Dermatitis

Cancer treatment

Radiation Therapy

Chemotherapy

Ulcers

Gastritis

Acid reflux

Ulcerative colitis

Gall bladder

Jaundice

Malaria

Thyroid disease

Tuberculosis

Hiatus hernia

Artificial joint/hip

Arthritis

Disability

Asthma

Persistent cough

Emphysema

COPD

Sleep apnea

AIDS

HIV infection

Diabetes HbA1c

Kidney trouble

Liver ciarrhosis

Depression

Psychiatric treatment

Anxiety

Seizures/Epilepsy

Hepatitis A/B/C/D/E

Glaucoma

Osteoporosis

Please elaborate further if you have the following conditions:

a. Asthma attacks: (how many times is the puffer used)

b. Prosthetic or artificial joint: (please include year of surgery):

c. Bleeding problems or disorder:

d. Replacement or repair to heart valve, infective endocarditis, heart condition from birth, or heart transplant: (please include year if applicable)

e. Heart or blood pressure problems:

f. Hepatitis, jaundice or liver disease: (please include year of diagnosis)

g. Any conditions that cause immunosuppression:

h. Form of disability:

i. Family history of diabetes, heart disease, cancer:

Yes

If yes, whom?

Do use tobacco or other tobacco-like substances?

Yes

If yes, frequency and how many years?

Previous Smoker?

Yes

If yes, how many years smoke free?

Do you drink alcohol?

Yes

If answered Yes, how many drinks per week?

Women only

Currently pregnant?

Yes

Not sure/Maybe

If yes, what is your expected delivery date?

Thinking of getting pregnant?

Yes

Not sure/Maybe

Are you currently breast feeding?

Yes

Hormonal imbalances?

Yes

Not sure/Maybe

Dental History Questionnaire

Previous Dental Clinic

Previous Dental Clinic Number

Last time seen by dentist

Last cleaning

Last dental x-rays

History of dental treatment if known:

Fillings

Implant/s

Crown/s

Root canal/s

Orthodontic treatment

Gum treatment

Any complications?

Yes

Oral hygiene habits:

a. Type of brush

Electric

Manual

b. Bristle type

Extra soft

Soft

Medium

Hard

c. Toothpaste name

d. How often do you floss?

e. How often do you brush?

f. Do you use a water pick?

Yes

g. Mouthwash:

Yes

h. Do you use fluoride products?

Yes

Check all that apply:

Painful/Sensitive/Tender teeth

Sensitivity to cold/hot/sweet/biting

Stabbing/throbbing/radiating pain(seconds/mins/hours)

Bleeding gums

Loose or moving teeth

Dry or burning mouth

Pain in jaw, temples, neck, ear

Clicking or popping sounds with chewing

Clicking or popping sounds with moving jaw

Jaw locking open

Jaw locking closed

Snoring at night/CPAP

Clenching or grinding

Headaches

Ulcer/lesions lasting more than 2 weeks

Numbness

Sinus pressure/frequent sinus infections

Are you happy with the colour of your teeth? * Required

Yes

Are you happy with present oral health/smile? * Required

Yes

Dental Insurance Information

Primary Insured's Name * Required

Date of Birth

MM slash DD slash YYYY

Insurance Company

Group #

Policy #

Relationship to subscriber

Do you have dual coverage?

Yes

Secondary Insured's Name

Date of Birth

MM slash DD slash YYYY

Insurance Company

Group #

Policy #

Relationship to subscriber

PATIENT CONSENT: The privacy of your personal information is a priority in our commitment to providing high-quality dental care. We recognize the importance of safeguarding your personal data and are dedicated to handling it responsibly, ensuring its collection, use, and disclosure are managed with the utmost care. All staff members who have access to your personal information are thoroughly trained in its proper handling and protection. In this consent form, we have detailed the measures our office takes to ensure that:

Only the necessary information is collected from you.
Your information is shared exclusively with your consent.
The storage, retention, and destruction of your personal information adhere to applicable legislation and privacy protocols.
Our privacy practices are fully compliant with the privacy standards set forth by our regulatory body, the Royal College of Dental Surgeons of Ontario, as well as relevant laws.

To provide safe and efficient patient care.
To ensure continuous high-quality service.
To assess your health needs.
To deliver appropriate healthcare services.
To inform you of available treatment options.
To facilitate communication, including scheduling and confirming appointments, follow-ups, and billing matters.
To offer and provide treatment and care related to the oral and maxillofacial complex and general dental care.
To communicate with other healthcare providers, including specialists and referring or peripheral dentists.
To submit dental claims for third-party adjudication and payment.
To meet legal and regulatory obligations, including providing patient records to the Royal College of Dental Surgeons of Ontario as required by the Regulated Health Professions Act.
To deliver patient charts and records to the dentist’s insurance carrier for liability assessment and damage quantification, if applicable.
To prepare documentation for the Health Professions Appeal and Review Board (HPARB).
To allow potential purchasers, practice brokers, or advisors to assess the practice or conduct an audit in preparation for a practice sale.
To invoice for goods and services.
To process credit card payments.
To collect outstanding accounts.
To ensure compliance with regulatory requirements.
To comply with applicable laws and regulations.

By signing this consent section of the Patient Consent Form, you acknowledge that you have provided informed consent for the collection, use, and/or disclosure of your personal information for the purposes outlined. Should a new purpose arise, we will seek your approval in advance.

Your information may be accessed by regulatory authorities by the Regulated Health Professions Act (RHPA) to enable the Royal College of Dental Surgeons of Ontario to fulfill its mandate under the RHPA, as well as for the defence of any legal matters.

Under no circumstances will our office provide your insurer with your confidential medical history. If such a request is made, we will promptly forward the information to you for review and obtain your explicit consent before any disclosure.

When we receive unusual requests for your information, we will contact you to obtain your permission before releasing any data. Additionally, we may inform you if we believe that such a release would be inappropriate. You have the right to withdraw your consent for the use or disclosure of your personal health information at any time.

PATIENT CONSENT: I have reviewed the information provided above, which outlines how your office will use my personal information and the measures being taken to protect it. I consent to Gumtree Dental Care collecting, using, and disclosing my personal information to the following individual(s).

I filled out this form to the best of my knowledge and confirm that the following information is correct.

Write your signature below.

Signature

Print Full Name

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

Home
About Us
Services
Patient Forms
FAQ’s
Contact Us

Privacy Policy
Sitemap
Accessibility Statement

modal-check

Child’s Oral Health

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

modal-check

Cosmetic Dentistry

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

modal-check

Dental Implants

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

modal-check

Invisalign

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

modal-check

Orthodontics

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

modal-check

Perfect Wedding Day Smile

Enter your information below.

"*" indicates required fields

First Name * Required

Last Name * Required

Phone * Required

Email * Required

By submitting this form, you agree to receive communications from our practice. You may unsubscribe at any time.

I understand that Protected Health Information (PHI) or sensitive information should not be included in this message.

This will close in 0 seconds

New Patient Form

Dental Care for the Whole Family

Child’s Oral Health

Cosmetic Dentistry

Dental Implants

Invisalign

Orthodontics

Perfect Wedding Day Smile