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1401 O'Connor Dr.  Unit 5,                 

East York, ON M4B 2V5, Canada

1401 O'Connor Dr.  Unit 5,                 

East York, ON M4B 2V5, Canada
Phone:  905-201-7001
Email: oconnordentaloffice@gmail.com

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ARE YOU CURRENTLY SUFFERING FROM A MEDICAL CONDITION, ILLNESS, OR INJURY?
HAVE YOU BEEN HOSPITALIZED IN THE LAST 12 MONTHS?
HAVE YOU BEEN SEEING A DENTIST REGULARLY?
DO ANY OF YOUR TEETH ACHE?
HAVE YOU EVER BEEN ADVISED TO TAKE ANTIBIOTICS BEFORE DENTAL APPOINTMENTS?
DO YOUR GUMS BLEED WHEN YOU BRUSH?
DO YOU HAVE ANY PAIN WHEN YOU CHEW?
DO YOU FEEL THAT YOU HAVE BAD BREATH?
HAVE YOU EVER BEEN IN A VEHICLE ACCIDENT OR EXPERIENCED ANY TRAUMA TO YOUR JAW?
HAVE YOU EVER HAD ANY IMPLANT SURGERY?
DO YOU HAVE OR HAVE YOU EVER HAD ;
DO YOU HAVE OR HAVE YOU EVER HAD AN ALLERGIC REACTION TO:
ARE YOU COVERED UNDER ANY DENTAL INSURANCE POLICY?
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NEW PATIENT FORM

All information is confidential and will remain with this office. The dental administration staff is available to help you complete any portion of this form. Pease fills out the following form to help us understand your physical condition. Thank you for your co-operation

REGISTRATION INFORMATION

Are you currently suffering from a medical condition, illness, or injury?
Have you been hospitalized in the last 12 months?
Do you feel that you have bad breath?
Do you have any pain when you chew?
Do your gums bleed when you brush?
Have you ever been advised to take antibiotics before dental appointments?
Do any of your teeth ache?
Have you been seeing a dentist regularly?
Have you ever had any implant surgery ?
Have you ever been in a vehicle accident or experienced any trauma to your jaw?
ARE YOU COVERED UNDER ANY DENTAL INSURANCE POLICY?

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DO YOU HAVE or HAVE YOU EVER HAD ;
DO YOU HAVE or HAVE YOU EVER HAD AN ALLERGIC REACTION TO:
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