COVID-19 SCREENING FORM Please fill out the mandated COVID-19 Screening Form below before your next appointment. CHILDREN’S PATIENT FORM (1) Patients Name* First Last Date* MM slash DD slash YYYY Address* Street Address City* Phone*BirthDate* MM slash DD slash YYYY Parent Name* First Last Primary Phone Number:*Work Phone Number:Home Phone Number:Best way to contact you:* Home Primary Work How did you hear about our office?* Please check any of the following that apply:* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Is another member of your family, or a relative a patient at our office?* Their name:* Is this your child's first visit to the dentist?* Date of your child's last visit to the dentist:* Date of your child's last dental xrays:* Date of your child's last dental cleaning:* Does your child have any sensitive teeth to hot/cold/sweets to bite on?* Does he or she suck on their thumb?* Has your child ever had any of the following?* Orthodontic Treatment (braces)? Root Canal and/or a Crown? Bite adjusted? Bleeding of their gums when brushing or flossing? Oral Surgery (extractions)? Clenching or grinding problems? A negative experience at a dental office? None of the above Does your child have or have they ever had any of the following?* Artificial Heart Valve Heart Murmur Heart Surgery Heart Pacemaker High Blood Pressure Rheumatic Fever Epilepsy or Seizures Fainting or Dizzy Spells Bruise Easily Diabetes: Diet or Medication controlled Hepatitis A Hepatitis B It has been suggested that your child needs pre-medication prior to dental treatment. None of the above Please check any of the following that apply:For ParentsDoes your child need aid when brushing their teeth?* Does your water contain fluoride?* Is your child currently taking any prescribed medications?* Has your child ever reacted to any type of medications?* Has your child had any serious injury/illness within the past two years that required medical attention?* Dental InsuranceDo you have dental insurance?* Primary Policy Holder* Insurance Company* Secondary Policy Holder* Parent Name ( required for under 18 years )* First Last Parent Signature ( required for under 15 years of age )*Use your mouse or finger to draw your signature above UPDATED MEDICAL HISTORY Patient Type* Adult Child Adult Under Guardianship Name of Guardian First Last Email* Self Identification* Man Woman Other Please Explain further DetailsName of Patient* First Last Date of Birth MM slash DD slash YYYY Address* Province*Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal code Primary Contact Number*Home PhoneWork PhoneBest number to reach you at?* Home Primary Contact Number Work Are you currently being treated for any medical condition or have you been treated within the past year?* Yes No Please Explain further DetailsWhen was your last medical checkup?* Has there been any change in your general health in the past year?* Yes No Please Explain further DetailsAre you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Explain further DetailsDo you have any allergies?* Yes No Please list allergies belowHave you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Explain further DetailsDo you have or have you ever had asthma?* Yes No Please Explain further DetailsDo you have or have you ever had any heart or blood pressure problems? Yes No Please Explain further DetailsDo you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?* Yes No Please Explain further DetailsDo you have a prosthetic or artificial joint?* Yes No Please Explain further DetailsDo you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Explain further DetailsHave you ever had hepatitis, jaundice or liver disease?* Yes No Please Explain further DetailsHave you ever been hospitalized for any illnesses or operations?* Yes No Please Explain further DetailsDo you have or have you ever had any of the following? Please check all that apply.* chest pain, angina rheumatic fever pacemaker steroid therapy seizures (epilepsy) heart attack mitral valve prolapse lung disease diabetes kidney disease stroke, TIA tuberculosis stomach ulcers thyroid disease shortness of breath heart murmur cancer arthritis drug/alcohol/cannabis use or dependency osteoporosis medications (e.g. Fosamax, Actonel) loss of hearing difficulty hearing None of above Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Explain further DetailsDo you smoke or use other nicotine products? Yes No Are you breastfeeding or pregnant?* Yes No Please Explain further DetailsDo you have a disability or are a person with visual impairment* Yes No Please Explain further DetailsGeneral Release I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.Signature*Use your mouse or finger to draw your signature aboveDate MM slash DD slash YYYY Contact Us Name First Last Email PhoneQuestion Or Comments
