Medical History Form

Please complete all required sections.
PATIENT INFORMATION
Fields with * are required
Start typing your address
PARENT / GUARDIAN INFORMATION (IF APPLICABLE)
Complete only if applicable
REFERRAL SOURCE
If you are a new patient, how did you hear about us?
Select Referral or Other to provide additional details.
MEDICAL HISTORY
Please answer the following questions
Are you currently being treated for any medical conditions? *
Have you been treated for any medical conditions within the last year? *
In the last 12 months, have there been any changes to your general health? *
Are you taking medications, non-prescription drugs or herbal supplements of any kind? *
Do you have any allergies to medications? *
Do you have any allergies to latex or rubber products? *
Do you have any other allergies? *
Have you ever had an uncommon or adverse reaction to any medicines or injections? *
Do you have or have you ever had asthma? *
SENSITIVE MEDICAL HISTORY
Do you have or have ever had a replacement or repair of a heart valve, infective endocarditis, congenital heart disease, or a heart transplant? *
Have you ever had hepatitis, jaundice or liver disease? *
Do you have a prosthetic or an artificial joint? *
Do you have a bleeding problem or a bleeding disorder? *
Have you ever been hospitalised for any illness or operations? *
Do you have any conditions or therapies that could affect your immune system? *
CONDITIONS CHECKLIST
Medical Conditions (check all that apply)
ADDITIONAL INFORMATION
Are there any conditions or diseases not listed above that you have or have had? *
Are there any diseases or medical problems that run in your family? *
Do you smoke or chew tobacco products? *
Are you nervous during dental treatment? *
Are you pregnant?
Do you identify as a patient with a disability? *
AUTHORIZATION & CONSENT
I authorize release; to my dental plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named dentist.
I hereby assign my benefits, payable from claims submitted manually & electronically, to GREENWOODS DENTAL & SURGICAL CENTRES and authorize payment directly to the establishment.
I acknowledge that I am FULLY RESPONSIBLE for any and all outstanding charges not paid in full, or in part, by my insurance provider(s) or other agency(ies), or in the event that I do not have an insurance provider. Further, I agree to remit, in full, any such outstanding payment(s) promptly upon receipt of an invoice, or verbal/written notification, for the outstanding charge(s).
FINAL CONFIRMATION
The Information I have given above is true to the best of my knowledge
SIGNATURE OF PATIENT OR PARENT/GUARDIAN
Date:
PHIA NOTICE
PHIA permits us to collect and use your personal health information. In certain circumstances, PHIA also allows us to share it with others both inside and outside our organisation. We do this for purposes such as:
  • To provide you with health care
  • To get payment for your care which could include private insurers
  • To do health system planning and research
  • To report as required by law
Unless you tell us not to, we can share your personal health information with any health care provider who has, is or will be providing you with health care. Members of your health care team are only allowed access to the information they need to give you the care you need. If you tell us not to share your information with a health care provider, we will not share your information unless permitted or required by law to do so. Please tell a member of your health care team if you do not want your information shared with a health care provider.