Medical History Questionnaire
Please Access the Medical History Questionnaire Form by Clicking one of the two options below:
Click the "PRINTABLE FORM" Tab below. You may Print Out the Form on your Home Computer, and then Complete it by hand. Remember to Bring the Completed Form with you to your Appointment;
Click the "ONLINE FORM" Tab below. You may then Complete the Form Online through our Confidential Portal. Remember to Submit the completed form prior to your Appointment.
Please Bring the Following Information with you to your Appointment:
- A Referral Slip from your Referring Doctor/Dentist
- Radiographs (X-rays), if Given to you by Your Referring Dentist
- A Current List of Medications
- A Form of Government Issued ID such as a Health Card or Driver's License
- Insurance Information
All Patients under 16 years of Age Must be Accompanied to their Appointment by a Responsible Adult who is Able to Give Consent for Care on Behalf of the Minor Patient.
Office Policy for Missed Appointment, Late Cancellation Notice and "No-Show" Appointment Policy
An appointment time has been reserved exclusively for you. To avoid a service charge of $250, a minimum of two (2) business days notice for cancelling or rescheduling your appointment is required. Please note that cancellation requests are effective on the date they are received during business hours. Requests submitted after hours, on weekends, or on statutory holidays will be considered received on the next business day. As per office policy, a patient who repeatedly misses appointments, provides insufficient notice for appointment cancellation, or does not show for an appointment may not be rescheduled. In these circumstances, future appointments may not be offered, treatment may be discontinued, and the referral may be returned to the referring dentist at the discretion of the practice. We appreciate your cooperation and understanding as we strive to provide timely specialty care to all patients.
*A no-show is defined as failing to attend a scheduled appointment without prior notice.