Forms | Endodontics at Yonge

First name

Last name

Email

Phone

Birthday

Year

Month

Day

Address

City

Postal Code

Who should we contact in case of emergency?

Relationship

Phone

Are you currently being treated for any medical conditions?

Are you currently taking any Medication?

Yes

No

If yes, please list all medications

Do you have any allergies?

Yes

No

If yes, please list all allergies

Have you ever had a reaction to medicines or injections?

Yes

No

If Yes, please explain any reactions

List any conditions you may have that were not mentioned above

Are you nervous during dental treatment?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Do you identify as a patient with a disability?

Yes

No

If Yes, please explain any disabilities

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Medical Forms