Please complete this form to help us provide you with the best possible dental care. Your medical history is important to your oral health. All information provided is confidential and will become part of your dental record. If you’d like to download the form and bring it in, please CLICK HERE. Thank you for taking the time to fill this out thoroughly.

Patient Name *

First Name

Last Name

Preferred Name

Title

Mrs

Birth Date *

YYYY

Gender

Male

Female

Email *

Mobile Phone *

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Insurance

Name of Insured *

First Name

Last Name

Insured's Date of Birth *

YYYY

ID # *

Group # *

Insurance Plan Name *

Insured's Employer Name

Patient's relationship to insured *

Self

Spouse

Child

Other

Secondary Insurance (if applicable)

Name of Insured

First Name

Last Name

Insured's Date of Birth

YYYY

ID #

Group #

Insured's Employee Name

Insurance Plan Name

Patient's relationship to insured *

Self

Spouse

Child

Other

Medical History

Please list all medications you are taking:

Please Mark any of the following to indicate Yes in response to the question:

Have you ever had complications following dental treatment?

Are you currently under the care of a physician due to a specific condition?

Have you been hospitalized within the last 5 years due to a surgery or illness?

Do you use tobacco or cannabis (smoking or chewing)?

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for you overall health and well-being.

*Pre-Medication

Artificial Joints

Depression/Anxiety

Epilepsy

Glaucoma

Asthma

Diabetes

Excessive Bleeding

HBP

LBP

Pacemaker

Stomach Problems

Multiple Sclerosis

Tumors

Nervous Disorders

Thyroid Disease

Hard to Freeze

Anemia

Blood Thinner

Dizziness/Fainting

Excessive Bruising

Hay Fever

Arthritis

Cancer

Rheumatic Fever

Hearing Disabled

Rheumatism

Heart Disease

Radiation Treatment

Heart Murmur

Respiratory Problems

Ulcers

Emphysema

Gastro-Intestinal

Allergy – Aspirin

Allergy – Codeine

Allergy – Sulpha

Allergy - Local Anaesthetic

Allergy – Iodine

Allergy – Morphine

STD

Hepatitis A

Hepatitis B

Hepatitis C

Rheumatoid Arthritis

High Cholesterol

Skin Rash

Kidney Disease

Allergy - Tetracycline

Allergy - Latex

Allergy - Erythromycin

Allergy - Penicillin

Allergy - Tylenol

Head Injury

Hives

HIV+ (AIDS)

TMJ

Liver Disease

Tuberculosis

Jaundice

Stroke

Osteoporosis

Other:

Are you Pregnant?

Yes

Due Date

YYYY

Within the past year, have there been any changes in your general health?

Yes

Your Primary Care Physician’s name, address, & phone number:

What is the reason for your dental visit today?

When was your last visit to the dentist (if to a different office)

If you could change anything about your mouth, teeth, or smile, what would it be?

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

Thank you!

Schedule Your Appointment Today

Name *

First Name

Last Name

Email *

Subject *

Message *

Thank you!

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Address:

7788 Jeanne D’Arc North
Ottawa, Ontario
K1C 2R5

Hours:

Monday – Thursday
7:30am - 4:15pm

Friday
8:00am - 12:00pm

Phone:

613-824-7288

Email: Admin@orleanswooddental.ca
Call us : (613) 824-7288