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Melbourne Dental Clinic
416.736.9800
Free Dentistry
Canadian Dental Care Plan
What Your Work Insurance Covers
Services
Cosmetic Dentistry
Kids Dentistry
Bone Grafting
Crowns
Dentures
Dental Sealants
Invisalign®
Implants
Mouth Guards
Root Canals
Teeth Whitening
Veneers
Wisdom Teeth
Smile Gallery
About Us
Forms
Contact
Free Dentistry
Canadian Dental Care Plan
What Your Work Insurance Covers
Services
Cosmetic Dentistry
Kids Dentistry
Bone Grafting
Crowns
Dentures
Dental Sealants
Invisalign®
Implants
Mouth Guards
Root Canals
Teeth Whitening
Veneers
Wisdom Teeth
Smile Gallery
About Us
Forms
Contact
MAP
Free Dental Info
Patient Forms
MEDICAL HISTORY FORM
DENTAL HISTORY FORM
PATIENT REGISTRATION FORM
Medical History
Name
Email
date of birth
In the past year, if your PERSONAL INFORMATION has changed please clarify below. If not, skip to MEDICAL HISTORY.
Street Address
City
Province
Zip
Phone Number
Physician
Physician: Phone Number
Pharmacy
Pharmacy Phone Number
Emergency Contact Name + Number
Relationship to Emergency Contact:
Send
PATIENT REGISTRATION
Name
Email
date of birth
phone
Street Address
City
Province
Zip
Phone Number
Are other family members patients at our office? If yes, names. *
Send
DENTAL HISTORY
Name
Email
date of birth
Do you have any specific dental problems or areas of concern?
Do you have dental examinations and preventive maintenance on a routine basis? Last visit
Do you think you have active decay or gum disease? *
Do you brush and floss on a regular basis? Discuss.
Have you been given good home care instructions?*
Are your teeth sensitive to: Hot, Cold, Sweets, Pressure *
Do you have any untreated dental problems that you are aware of? Discuss
Have you ever had? *
Orthodontic Treatment
Oral Surgery
Periodontal Treatment
Your Bite Adjusted
Worn a bite plate/night guard
Have you noticed?
Loosening of your teeth
Food catching between your teeth
Pain/Swelling of gums
Sores or growths in your mouth
Bleeding gums when brushing & flossing
Bad breath
Do you smoke or chew tobacco?
Have you heard of Periodontal Disease?
Yes
No
Do you want to keep your remaining teeth?
Yes
No
Are you pleased with the quality of your smile?
Yes
No
Have you experienced?
Clicking of the jaw?
Pain (joint, ears, side of face)
Difficulty in opening/closing your mouth
Difficulty in chewing, favor one side
Bleeding gums when brushing & flossing
If you could change your smile, what would do? (check all that apply)
Whiten Teeth
Straight Teeth
Lengthen Teeth
Shorten Teeth
Replace Teeth
Fix Spaces
Replace Fillings
Less Gummy
Everything!
Nothing
Signature
Date
Send