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Forms

Forest Hill Dental Forms

Forest Hill Dental provides our patients with a downloadable print version or our simple easy to fill out confidential online version. Please select the form in which you would like to submit.

Health History Form

Health History Form

Online Version of Health History Form Printable PDF of Health History Form
Transfer of Records

Transfer of Records

Online Version of Transfer of Records Printable PDF of Transfer of Records
Privacy Act Form

Privacy Act Form

Online Version of Privacy Act Form Printable PDF of Privacy Act Form

Patient Health Record

Your co-operation in filling out this questionnaire is essential in aiding us to perform the highest standard of dental care. All information is strictly confidential and will remain with this office.

Salutation

Dr. Mr. Mrs. Ms.

First Name

Middle Name

Last Name

Date Of Birth

Sex

Male Female

Marital Status

Single Married Widowed

Address

Street Address

Unit Number

City

Province

Postal Code

Home Phone

Business Phone

Occupation

Employer

Emergency Contact

Emergency Contact's Phone

Insurance

Do you have Dental Insurance?

Yes No

Insurance Company

Company Insurance: Policy Holder Name

Company Insurance: Company Name

Company Insurance: Policy #

Company Insurance Identification #

Confidential Medical History

Family Physician

Address

Phone

Have you been under a physician care during the past 2 years?

Yes No

Have you been treated in a hospital in the past 2 years?

Yes No

Have you had major surgery?

Yes No

If female: are you taking hormones or birth control?

Yes No

Have you had cankers or cold sores on your lips, tongue, gums or body?

Yes No

Are you taking or have you taken any prescription drugs during the past year?

Yes No

Are you allergic to

Penicillin Codeine Local Anesthetics Other

Do you have or have you had:

HIV+ / AIDS
Nervous disorder
Herpes
Stroke
High Blood Pressure
Low Blood Pressure
Thyroid disorder
Epilepsy
Cancer
Psychiatric Care
Venereal Disease
Chest Pain
Heart Murmurs
Diabetes
Shortness of Breath
Swollen Ankles
Heart Trouble/Attack
Heart Disease
Liver disorder
Sinus Problems
X-Ray Therapy
Hepatitis
Arthritis
Malignant Hyperthermia
Kidney Disorder
Ulcers
Abnormal Weight Change
Blood disorders
Glaucoma
Artificial Heart Valves
Allergies
Drug Dependency
Congenital Heart Lesions
Pacemakers
Organ Transplant
Artificial Joints
Chemotherapy
Jaundice
Prolonged Bleeding
Prolonged Cough
Radiation Therapy
Rheumatic Fever
Polio
Tuberculosis
Angina
Fainting Spells

Confidential Dental History

Previous Dentist

Whom may we thank for referring you?

When was your last dental visit?

How often did you see your dentist?

Are you having any dental problems that require immediate attention?

Yes No

Do any of the following cause tooth discomfort?

Hot Cold Sweets Chewing

Have you had periodontal treatment?

Yes No

When?

Do your gums bleed or are they sore while cleaning?

Yes No

Do you clench or grind your teeth?

Yes No

Do your jaws ever feel tired or ache?

Yes No

Do your jaws ever click or pop?

Yes No

Can you comfortably chew on both sides of your mouth?

Yes No

Do you have frequent headaches?

Yes No

Do you usually have many cavities

Yes Somewhat No

How do you feel about the appearance of your smile?

Have you ever had any dentistry done to improve your appearance?

Yes No

If so, are you pleased with the result? Please comment

Yes No

Do you currently experience any of the following?

Loose Teeth Bad Breath Stained Teeth Unsatisfactory Dentures Spaced or Crooked Teeth
Neck Pain Gagging Missing Teeth Unexplained Nosebleed Discoloured Dark Teeth

Are you tense during dental visits?

No A Little Moderately Very Tense Would prefer to be sedated

Please add anything you feel is important

Office Policy

1. PAYMENTS: Payment for service is expected at the end of each visit. Certain circumstances require special considerations. Please discuss these with your dentist.

2. APPOINTMENTS: In order to treat you effectively, we will reserve an appointment time solely for you. We require your co-operation in keeping these appointments. If you cannot keep your appointment time, we require 48 hours notice. Otherwise a fee will be assessed.

Consent For Treatment

This is to certify that I, the undersigned, have read the forgoing and consent to the performing of the dental procedures agreed to be necessary or advisable. I will assume responsibility for fees associated with those procedures.

Patient's Signature

Date: