Dentistry On Dufferin

Toronto

2992 Dufferin St. Toronto, ON, M6B 3T3
info@dentistryondufferin.ca
Tel: 416-785-5555


Dentistry On Dufferin Patient Information
Do you have Dental Insurance?
In case of Emergency Notify.

OFFICE POLICY

We require at least **48 hours notice** for any appointment cancellations or rescheduling. This allows us to offer the time to other patients who may need urgent care. A fee may be charged for missed appointments without sufficient notice.

Payment is required at the time of service. We accept major credit cards, debit, and cash. We will gladly help you process your insurance claims.

CONFIDENTIAL MEDICAL HISTORY

1. Date of last complete physical examination

2. Are you currently under a physician’s care?

3. Do you have frequent headaches?

4. Do you smoke?

5. Do you drink alcohol?

6. Do you do recreational drugs?

7. Do you routinely take vitamins, herbal substances, or natural products?

8. Are you taking any medications?

9. Have you taken any prolonged medication in the past?

10. Have you taken cortisone or steroids?

11. Have you ever been hospitalized for any surgery?

12. Are your ankles often swollen?

13. Have you gained or lost excessive weight recently?

14. Are you pregnant?

15. Are you sensitive or have you ever had an adverse reaction to:
16. Are you allergic or have adverse reactions to:

17. Are you allergic or have adverse reactions to any other drugs?

18. Have you ever been treated for or told you have any of the following:

19. Have you ever experienced heavy bleeding?

20. Is there anything else we should know?

21. Have you been diagnosed with any other disease,
condition or problem not listed above?

22. Is there anything about your health we should be aware of?

23. Do you wish to speak to the doctor privately about any problem or medical condition(s)?

CONFIDENTIAL DENTAL HISTORY

24. Date of last complete exam

25. Date of last cleaning

26. Date of last x-rays

27. Did you see your last dentist regularly?

28. How often did you see your last dentist?

What was done at that time?

29. Have you ever been advised to take antibiotics before a dental treatment?

30. Have you ever experienced difficulty or heavy bleeding following extractions?

31. Have you ever had gum treatment or surgery?

32. Have you had any orthodontic treatment?

33. Have you ever had an unpleasant dental experience?

34. How can we make your dental experience more pleasant?

35. Is there anything else we should know?

36. What brings you to the office today?

37. Are you in any discomfort?

38. Do you have or have you experienced:

39. Does food get caught between your teeth?

40. Do you have any sore spots in your mouth?

41. Have you had any teeth replaced?

42. Would you like to learn more about permanent tooth replacement?

43. Have you ever been given local anesthesia (Freezing)?

44. Have you ever been given general anesthesia?

45. Are you satisfied with the appearance of your teeth?

46. Are you anxious to keep your natural teeth?

47. Are you tense during dental visits?

48. Are you interested in a method to calm your nerves during dental visits?

PATIENT CONSENT

This is to certify that I, the undersigned, consent to the performing of the dental procedures agreed to be necessary or advisable including the use of local anesthetic as indicated and I will assume responsibility for fees associated with those procedures.

Attached to this consent form, we have outlined what our office is doing to ensure that:

  • Only necessary information is collected about you
  • We only share your information with your consent
  • Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
  • Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.

In this office, Our Team acts as the Privacy Information Officer.

Attached to this consent form, we have outlined what our office is doing to ensure that:

I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.

I know that your office has a Privacy Code, and I can ask to see the code at any time.

Sign inside the box above.

By clicking submit, your information will be securely transmitted to our clinical records department.