647-828-8000
info@dentistryatsheppard.com
2048 Sheppard Ave E, North York
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First Name:
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Last name:
Address:
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City:
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Province:
Postal Code:
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Home phone:
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Work:
Cellular:
Email
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Birthdate:
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OHIP Number:
Responsible party/ emergency contact name:
Phone
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Relationship:
How did you hear about AIMS Dentistry?
Primary insurance information:
Name of insured:
Date of birth:
Relationship to patient:
Employer:
Insurance carrier:
Policy number:
Member ID number:
Secondary Insurance info:
Name of insured
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Relationship to patient:
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Insurance carrier:
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Member ID number:
Medical History
Are you under a physician care now?
Yes
No
If Yes
If Yes
Have you ever been hospitalized or had a major operation?
Yes
No
If Yes
If Yes
Have you ever had a serious head or neck injury?
Yes
No
If Yes
If Yes
Are you taking any medications, pills, or drugs?
Yes
No
If Yes
If Yes
Do you take, or have you taken Phen-Fen or Redux?
Yes
No
If Yes
If Yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
If Yes
If Yes
Are you on special diet?
Yes
No
If Yes
If Yes
Are you on special diet?
Yes
No
If Yes
If Yes
Women: Are you...
Pregnant/ Trying to get pregnant ?
Nursing?
Taking oral contraceptives?
Are you allergic to the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Other?
If Yes
If Yes
Do you have, or you had, any of the following?
Aids/HIV Positive
Yes
No
Excessive Thirst
Yes
No
Mitral Valve Prolapse
Yes
No
Alzheimer Disease
Yes
No
Fainting Spells/Dizziness
Yes
No
Osteoporosis
Yes
No
Anaphylaxis
Yes
No
Frequent Cough
Yes
No
Pain in Jaw Joints
Yes
No
Anemia
Yes
No
Frequent Diarrhea
Yes
No
Parathyroid Disease
Yes
No
Angina
Yes
No
Frequent Headaches
Yes
No
Psychiatric care
Yes
No
Arthritis/Gout
Yes
No
Genital Herpes
Yes
No
Radiation Treatment
Yes
No
Artificial Heart Valve
Yes
No
Glaucoma
Yes
No
Recent Waight Loss
Yes
No
Artificial Joint
Yes
No
Hay Fever
Yes
No
Renal Dialysis
Yes
No
Asthma
Yes
No
Heart Attack/Failure
Yes
No
Heart Attack/Failure
Yes
No
Blood Disease
Yes
No
Heart Murmur
Yes
No
Rheumatism
Yes
No
Blood Transfusion
Yes
No
Heart Pacemaker
Yes
No
Scarlet Fever
Yes
No
Breathing problems
Yes
No
Heart Trouble/Disease
Yes
No
Shingles
Yes
No
Bruise Easily
Yes
No
Hemophilia
Yes
No
Sickle Cell Disease
Yes
No
Cancer
Yes
No
Hepatitis A
Yes
No
Sinus Trouble
Yes
No
Chemotherapy
Yes
No
Hepatitis B or C
Yes
No
Spina Bifida
Yes
No
Chest Pains
Yes
No
Herpes
Yes
No
Stomach/Intestinal Dis.
Yes
No
Cold Sores/Fever Blisters
Yes
No
Hight Blood Pressure
Yes
No
Stroke
Yes
No
Congenital Heart Disorder
Yes
No
High Cholesterol
Yes
No
Swelling of Limbs
Yes
No
Convulsions
Yes
No
Hives or Rush
Yes
No
Thyroid Disease
Yes
No
Cortisone Medicine
Yes
No
Hypoglycemia
Yes
No
Tonsillitis
Yes
No
Diabetes Hemophilia
Yes
No
Irregular Heartbeat
Yes
No
Tuberculosis
Yes
No
Drug Addiction
Yes
No
Kidney Problems
Yes
No
Tumors or Growths
Yes
No
Easily Winded
Yes
No
Leukemia
Yes
No
Ulcers
Yes
No
Emphysema
Yes
No
Liver Disease
Yes
No
Venereal Disease
Yes
No
Epilepsy or Seizures
Yes
No
Low Blood Pressure
Yes
No
Yellow Jaundice
Yes
No
Excessive Bleeding
Yes
No
Lung Disease
Yes
No
Have you ever had any serious illness not listed above?
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
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