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HOME
ABOUT
Reviews
PROCEDURES
Cleanings & Prevention
Dental Exams & Cleanings
Dental X-Rays
Digital X-Rays
Fluoride Treatment
Home Care
Brushing and Flossing – A Simple Guide
Oral Hygiene Aids
Dental Sealants – What You Need to Know
Dental Restorations
Composite Fillings
Root Canal Therapy
Crowns (Caps)
Fixed Bridges
Inlay Restorations
Onlay Restorations
Dentures & Partial Dentures
Cosmetic Dentistry
Porcelain Crowns (Caps)
Porcelain Fixed Bridges
Porcelain Inlays
Porcelain Onlays
Porcelain Veneers
Tooth Whitening
Venus Teeth Whitening
Periodontal Disease
What is Periodontal (Gum) Disease?
Diagnosis
Treatment
Maintenance
Invisalign
Sedation Dentistry
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5 Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
Testimonials
FAQs
BLOG
News
SERVICE AREAS
Kitchener Ontario
Alpine Ontario
Bridgeport Ontario
Brigadoon Ontario
Centreville Ontario
Country Hills Ontario
View All Areas
BOOK AN APPOINTMENT
5-Year Medical Update Form
Lancaster Dental
493 Lancaster Street West, Suite #206
Kitchener, ON N2K 1L8
Phone: 519-578-9670
Today's Date
*
DD slash MM slash YYYY
Patient Name
*
First
Middle
Last
Date of Birth
*
Day
Month
Year
Age
*
Family Status
*
Single
Married
Separated
Divorced
Widowed
Gender
What sex were you assigned at birth?
Male
Female
What is your current gender identity?
Male
Female
Other
Specify Current Gender
Preferred Gender Pronoun
A pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you!
What pronouns do you prefer that we use when referring to you? (check all that apply)
She/her/hers
He/him/his
They/them/theirs
Other
Specify pronoun
Contact Information
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
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Armenia
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Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
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Belize
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Bosnia and Herzegovina
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Bouvet Island
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British Indian Ocean Territory
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Burkina Faso
Burundi
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Cameroon
Canada
Cayman Islands
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Chile
China
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Colombia
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Cook Islands
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Croatia
Cuba
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Cyprus
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Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
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Sierra Leone
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Sint Maarten
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Solomon Islands
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South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
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Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
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Tonga
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Tunisia
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Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
Email
*
Work Phone
Extension Number
Health Card Number
Family Physician
*
First
Last
Physician's Phone
*
In Case of Emergency, We should notify:
*
First
Last
Relationship
*
Phone
*
Employer Name
Occupation
Medical & Dental Information
Do you or have you ever had an adverse reaction or allergy to:
Antibiotic
Yes
No
Which Antibiotic
Aspirin/Advil
Yes
No
Codeine
Yes
No
Latex
Yes
No
Local Anesthetics/Novocain
Yes
No
Other
Yes
No
Please Specify
Do you take blood thinners (e.g Coumadin, Plavix, etc.)
*
Yes
No
Specify the date and score of most recent INR
Do you take any other medications, vitamins or supplements
*
Yes
No
List any medications and dosage (including Herbal)
*
Have you ever had any of the following? Please check those that apply:
Neural
Seizures/Epilepsy
Seizures/Epilepsy
Dizziness
Nervous/Mental Disorders
Stroke
Depression
Cardiovascular
Angina
Heart Attack
Bleeding Disorder
High/low Blood Pressure
Heart Disease
Pacemaker
Rheumatic fever
Heart Murmur
Pulmonary
Asthma / COPD
Difficulty breathing
Respiratory problems
Tuberculosis
Infectious
AIDS/ HIV
Hepatitis A B C
Venereal Disease
Immune
Hay fever
Allergy
Neoplastic
Cancer
Growths/Tumors
Radiation/Chemo
Digestive
Acid reflux Disease
Stomach Problems
Ulcers
Inflammatory
Arthritis
Rheumatism
Osteoporosis
Other
Diabetes
Artificial Joints
Glaucoma
Sinus Problems
Liver Disease
Kidney Disease
Sleep Apnea
Organ Transplant
Thyroid problems
Where do you keep your inhaler?
Specify any of the above conditions
Surgery Details
If you had any surgeries please specify the surgery date and information.
Are there any conditions or diseases not listed above that you have or have had?
*
Yes
No
What are they?
Have you ever had any complications following dental treatment?
*
Yes
No
Please explain
Have you or anyone related to you ever had problems with local anesthetic?
*
Yes
No
Please explain
Are you pregnant or is it possible you are pregnant?
*
Yes
No
Due Date
Day
Month
Year
Are you now under the care of a physician, regarding an ongoing medical issue?
*
Yes
No
Please explain
Do you have any health problems that need further clarification?
*
Yes
No
Please explain
Do you smoke?
*
Yes
No
Used to
How many cigarettes a day?
When did you quit?
Day
Month
Year
Do you use any recreational drugs?
*
Yes
No
Please list which kind:
Do you have a prosthetic or artificial joint ?
*
Yes
No
Where ?
Do you have or have you ever had replacement or repair of a heart valve, infection of the heart(i.e. infection endocarditis), a heart condition from birth (i.e. congenital heart disease) or heart transplant?
*
Yes
No
When was your last dental visit ?
*
When did you last have dental x-rays ?
*
How often do you floss your teeth ?
*
How often do you brush your teeth ?
*
Have you been seeing a dentist regularly ?
*
Yes
No
Do any of your teeth ache ?
*
Yes
No
Do your gums bleed when you brush ?
*
Yes
No
Do you have pain when you chew ?
*
Yes
No
Do you feel you have bad breath ?
*
Yes
No
Please list anything else not mentioned above regarding your past dental history.
Consent for Services & Office Agreement
* I understand that my family’s appointments are valuable, and that
2 Business days
must be given if we are unable to attend appointments. A missed standard appointment may incur a fee.
*I will be required to
pay for my family treatment at each visit
. For treatment involving laboratory work, I will be required to place a deposit for the estimated lab work required (this is separate from Dental office fees).
*I understand that outstanding account balances will be passed to a Credit Agency and/or to the Ontario Court System.
*I understand there are premium times in great demand. If I am not attending these premium appointments and thus preventing other patients from making effective use of these times, I will be required to make use of regular hours for treatment.
*
My dental insurance plan is a contract between myself and the organization providing me with the coverage
. It is my responsibility to ensure that the treatment I request is covered. However, Lancaster Dental will help me to the best of their abilities to ensure accurate and timely completion of my insurance forms. Lancaster Dental has
NO
knowledge of what is covered by my insurance plan. If I have a booklet, Lancaster Dental will be able to interpret it for me. Many plans require Pre-Determinations to be forwarded for more extensive treatment. Lancaster Dental will complete these for me. To avoid any delays in receiving my payment from my insurance company I must send my claim immediately, if it is not submitted electronically.
* Lancaster Dental also understands that your time is valuable so we are intent on starting your appointment on time. With the possible exception of short notice emergencies (which all of us might get and we would like to be seen as soon as possible) we will not double book appointments.
* Lancaster Dental will always make every attempt to see emergency cases promptly.
* Lancaster Dental will accept Visa, MasterCard, debit, cash or cheque.
* Lancaster Dental will propose my dental treatment with my long-term dental health in mind, and will do their best to give an accurate estimate.
Consent for Collection, Use and Disclosure of Personal Information
* I agree that Lancaster Dental has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information. I can request to see a copy of the consent form and agree the personal information may be collected, used and disclosed as set out in the Privacy Policy of the Office which is in accordance with the Personal Health Information Protection Act, 2004.
Consent
*
I have read the above conditions of treatment and payment and agree to their content. I confirm that best to my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian (Type in Your Name)
Date
*
DD slash MM slash YYYY
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