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Date of Birth*

Address*

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Primary Contact Number*

Home Phone

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Emergency Contact Phone Number*

Name of Family Physician

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Name of Dental Insurance Company*

Name of Policy Holder*

Certificate Number*

Policy Number*

Date of your last Dental Cleaning

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When was your last medical checkup?*

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Expected Due Date ?*

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General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.

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Updated Medical History

General Release