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Home
Our Services
Family Dentistry
Root Canal Treatment
Dental Hygiene
Emergency Dentist
Porcelain Veneers
Teeth Whitening
Wisdom Teeth Removal
Cosmetic Dentistry
Crowns & Bridges
Gum Treatment
Dentures
Smile Makeover
Invisalign Treatment
Dentist for Kids
Dental Bonding
About Us
Appointment
Contact us
Blog
FAQ
Resource
New Patients Form
Post Operative Dental
After a Root Canal
After The Extraction
Night Guard
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Home
Our Services
Family Dentistry
Root Canal Treatment
Dental Hygiene
Emergency Dentist
Porcelain Veneers
Teeth Whitening
Wisdom Teeth Removal
Cosmetic Dentistry
Crowns & Bridges
Gum Treatment
Dentures
Smile Makeover
Invisalign Treatment
Dentist for Kids
Dental Bonding
About Us
Appointment
Contact us
Blog
FAQ
Resource
New Patients Form
Post Operative Dental
After a Root Canal
After The Extraction
Night Guard
Home
Our Services
Family Dentistry
Root Canal Treatment
Dental Hygiene
Emergency Dentist
Porcelain Veneers
Teeth Whitening
Wisdom Teeth Removal
Cosmetic Dentistry
Crowns & Bridges
Gum Treatment
Dentures
Smile Makeover
Invisalign Treatment
Dentist for Kids
Dental Bonding
About Us
Appointment
Contact us
Blog
FAQ
Resource
New Patients Form
Post Operative Dental
After a Root Canal
After The Extraction
Night Guard
(289) 878-5225
Book Online
Health And Dental History
Name
(Required)
First
Last
Date of Birth:
(Required)
MM slash DD slash YYYY
Health Card #:
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone:
work Phone:
Mobile Phone:
Email:
Best method of contacting me
Phone
Email
Occupation:
Business Name:
Emerg. Contact, Name:
Mobile Phone:
Relationship:
How did you hear about our office
(Required)
Friend/Family
Internet
Walking
Others
Name of Family Doctor:
Mobile Phone:
Pharmacy Name:
Mobile Phone:
INSURANCE DATA: (Please provide the insurance cards to our receptionist)
Insurance Company:
Employer:
Policy holder name:
Date of Birth:
MM slash DD slash YYYY
1-Are you being treated for any medical conditions at present or within the past two years?
(Required)
Yes
No
If yes, what it is?
2-When was your last medical checkup with your family doctor?
3-Are taking any medications, prescribed or non-prescription drugs or herbal/ supplement of any kind?
(Required)
Yes
No
If yes, what conditions?
4-Do you have any allergies?
(Required)
Yes
No
If yes, please list using the following categories:
Medications:
penicillin
Codeine
Sulfa
Advil
aspirin
Local Anesthesia
Nitrous Oxide
Others Medications:
Latex/ Rubber Products:
Others(e.g. Hay Fever, Foods)Others(e.g. Hay Fever, Foods)
5- Have you had an adverse reaction to any medications or injections?
(Required)
Yes
No
6- Do you have or have you had any heart/blood pressure (High/Low) problems?
(Required)
Yes
No
7- Have you ever been hospitalized for any illnesses or operations? If yes, please explain:
(Required)
Yes
No
8- Are you taking any blood thinners?
(Required)
Yes
No
If yes, please list:
9- Do you have or have you ever had any of the following? Please select
Artificial Value
Arthritis
Blood diseases/ Prolonged Bleeding
Cancer
Chest Pain/ Angina
Diabetes Type l/ll
Drug/alcohol dependency
Heart Attack
Heart Murmur
Hepatitis (A,B,C)
High Cholesterol
Jaundice/ Liver Disease
Kidney Disease
Leukemia
Lung Disease
Osteoporosis
Rheumatic Fever
Seizures (Epilepsy)
Shortness of Breath
Steroid Therapy
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis
10- Are there any conditions or diseases not listed that you have or had?
(Required)
Yes
No
If yes, please list?
11- Do you or have you ever had asthma?
(Required)
Yes
No
12- Is there any family history of disease/medical problem? (E.g. diabetes/ cancer/ heart disease)
(Required)
Yes
No
13- Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
(Required)
Yes
No
14- Do you have a prosthetic or artificial joint (i.e hip/ knee/ etc…)?
(Required)
Yes
No
15- Have you ever been advised to take antibiotics (premedication) before visiting the dentist?
(Required)
Yes
No
16- Do you have a bleeding problem or bleeding disorder?
(Required)
Yes
No
17- Do you smoke/ chew tobacco products? If yes, for how long and how much?
(Required)
Yes
No
WOMEN ONLY
18- Are you pregnant? If yes, what is the expected delivery date?
Yes
No
19- Are you nursing/ breast feeding?
Yes
No
20- Do you take birth control? If yes, which brand?
Yes
No
DENTAL HISTORY
21- Reason for dental visit?
22- When was your last dental visit?
23- Have you ever had any complication following dental treatment?
(Required)
Yes
No
24- Have you had any complications or unpleasant dental experiences?
(Required)
Yes
No
Please explain.
25. How often do you brush your teeth?
How often do you floss your teeth?
What are you concerned about (Mark all that applies): Please select
(Required)
Your smile
Chewing/Bite
Bleeding Gums
Missing Teeth
Food getting stuck
Infected Teeth
Bad breath
Loose Teeth
Sensitive Teeth
Painful Teeth
Broken Tooth/ Filling
Grinding/ Clenching
Discolored/ Yellow Teeth
Dry Mouth
Crowded/ Spaced Teeth
General Release and Consent:
General Release and Consent:
I, the undersigned, certify that I have provided an accurate and complete personal and medical/dental history and financial information, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any
questions regarding my medical/ dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental office at once. I authorize the dentist to perform diagnostic procedures as may be required to determine the necessary treatment. I also authorize the dentist to take X-rays, study models, photographs or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I also authorize the dentist to perform any and all forms of treatment, medication and therapy, I consent that X-rays and photographs to be used by Dr. Khafaji and his associates for education purposes. I understand that information provided from or to my medical doctor or another health care provided may be necessary. I have been advised of the privacy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that the responsibility of the payment of dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services, and these fees are due and payable at the time services are rendered, unless a financial agreement has been made.
Patient/Guardian Name
(Required)
First
Last
Signature
(Required)
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Date
(Required)
MM slash DD slash YYYY