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Home
About
Services
Cosmetic Dentistry
Teeth Cleaning
Dental Veneers
Invisalign
Restorative Dentistry
Dental Implants
Dental Bridges
Dental Crowns
Root Canal Therapy
White Fillings
Dental Surgery
Bone & Gum Grafting
Sedation Dentistry
Wisdom Teeth Removal
Emergency Dentist
Forms
Medical History Form
Referral Form
Blog
Contact
[email protected]
416-636-6730
416 636 1436
1394 Wilson Ave Toronto, Ontario, Canada M3M 1H8
New Patient Medical History Form
Toronto Smile Centre
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Name
*
Layout
Date of Birth
*
Today's Date
*
Reason you are here today
Last dental appointment
Reason for last dental visit
Dental History
Sensitivity issues
Gum issues
Any Anesthetic reactions in past
Anxiety
Joint issues
Grinding
Have ever had the following conditions? (Check if yes)
Personal Medical History
Anemia
Arthritis
Asthma
Cancer
Chronic Obstructive Pulmonary Disease (COPD)
Disease
Clotting Disorder
Congestive Heart Failure
Crohn's Disease
Depression
Diabetes
Emphysema
Endocrine Problems
GERD
Glaucoma
Hepatitis
HIV/AIDS
Hypertension
Kidney Disease
Myocardial Infarction
Peptic Ulcer Disease
Seizures
Stroke
Ulcerative Colitis
Bleeding Disorders
Heart Conditions
Have ever had the following conditions? (Check if yes)
Personal Medical History (Past Surgeries)
Medications
Allergies
Family History
Anemia
Blood Clots
Stroke
Anesthesia Reaction
Hepatitis
Diabetes
Heart Disease
High Blood Pressure
Bleeding Problems
Cancer
Other
Has anyone in your family had any of the following conditions? (Check if yes, and indicate relationship to you)
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Other
Relationship
Submit
92178
Contact Us
Toronto Smile Centre
416-636-6730
416 636 1436
[email protected]
1394 Wilson Ave Toronto, Ontario, Canada M3M 1H8
Schedule an appointment
Contact Us
416-636-6730
[email protected]
416 636 1436
1394 Wilson Ave
Toronto, Ontario, Canada,
M3M 1H8
Our Hours
Monday
8AM - 8PM
Tuesday
8AM - 8PM
Wednesday
8AM - 8PM
Thursday
8AM - 8PM
Friday
8AM - 4PM
Saturday
8AM - 4PM
Sunday
Closed
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