Patient Consent Form & Medical History Questionnaire

I have reviewed the above information regarding the collection, use, and disclosure of the personal information, and have been given the opportunity to ask questions about the steps your office is taking to protect this information. I acknowledge and agree that the office of Y. Lenga Dentistry Professional Corporation can collect, use and disclose the personal information as described above, and in accordance with the Privacy Code of their office. *

I agree

Patient or Parent/Guardian Name *

First

Last

Patient or Parent/Guardian Signature *

Witness Name *

First

Last

Witness Signature *

Date *

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone Number (Home) *

Phone Number (Work)

Email *

Email

Confirm Email

Who referred you to our office?: *

Your General Dentist: *

Your Occupation:

In case of emergency, we should contact: *

Relationship: *

Day-time Phone Number *

Health Card Number (Format: ########## AA) *

Name of Family Doctor: *

Doctor's Phone Number or Address: *

Current Height and Weight: *

Primary Insurance Carrier:

Policy Number:

ID Number:

Name of Insured (if different from yourself):

D.O.B. of Insured (if different from yourself):

Secondary Insurance Carrier:

Policy Number:

ID Number:

Name of Insured (if different from yourself):

D.O.B. of Insured (if different from yourself):

Are you being treated for any medical condition at the present, or have you been treated within the past year. *

Yes
No
Not sure/maybe

If yes, why?

When was your last medical checkup? *

Has there been any change to your general health in the past year? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you allergic to any medications? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you allergic to latex/rubber products? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have any other allergies (e.g. hay fever, foods)? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever had a peculiar or adverse reaction to any medications, medicines or injections? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had asthma? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had any heart or blood pressure problems? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had a heart murmur, mitral valve prolapsed or rheumatic fever? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have a prosthetic or artificial joint? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever been advised by your doctor to take antibiotics before dental treatment? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have any conditions or therapies that could affect your immune system (leukemia, HIV/AIDS, radiotherapy, chemotherapy)? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever had hepatitis, jaundice or liver disease? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have a bleeding disorder, or bleed excessively? *

Yes
No
Not sure/maybe

If yes, please explain:

Have you ever been hospitalized for any illness or operations? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you have, or have you ever had any of the following? Please check all that apply:

Are there any conditions or diseases not listed above that you have, or have had in the past? *

Yes
No
Not sure/maybe

If yes, please explain:

Are there any diseases or medical problems that run in your family (diabetes, cancer, heart disease)? *

Yes
No
Not sure/maybe

If yes, please explain:

Do you smoke or chew tobacco products? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you nervous during dental treatment? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you pregnant or currently breast feeding? *

Yes
No
Not sure/maybe

If yes, please explain:

Are you taking any medications, oral or injection, past or present for osteoporosis? *

Yes
No
Not sure/maybe

If yes, please explain:

Is there any additional information regarding your health that you need to share? *

Yes
No
Not sure/maybe

If yes, please explain:

Rate your smile from 1-5 *

What do you like the most about your smile? *

What would you like to fix about your smile? *

To the best of my knowledge, the above information is correct: *

I agree

Signature *

Date *

55 St. Clair Ave. W. #127,
Toronto, ON M4V 2Y7

info@lengaperio.com

416-929-9009

416-929-4866

Mon-Thurs 8am-4:30pm
Friday Appointments Available By Special Request

Patient Consent Form & Medical History Questionnaire

55 St. Clair Ave. W. #127,Toronto, ON M4V 2Y7

info@lengaperio.com

416-929-9009

416-929-4866

Mon-Thurs 8am-4:30pmFriday Appointments Available By Special Request

55 St. Clair Ave. W. #127,
Toronto, ON M4V 2Y7

Mon-Thurs 8am-4:30pm
Friday Appointments Available By Special Request