Meet the Team
Dental Services
Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
Metcalfe Dental Experience
613-237-7177
Book An Appointment
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Patient Information Form
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Please Check
*
Dr.
Mr.
Mrs.
Ms.
Miss.
Please check Patient is a(n)
*
Adult
Child
Adult under Guardianship
Name of Guardian
Patient First Name
*
Patient Last Name
*
How did you hear about Metcalfe Street Dental?
Address
*
City
*
Postal Code
*
Email
*
Home Phone
*
Work Phone
Cell Phone
Other Phone
Date of Birth
*
Name of Dental Insurance Company
Policy #
Certificate #
Name of Policy Holder
Date of Birth
Section Break
*I authorize release to my insurance company, information contained in claims submitted electronically.
Emergency Contact Name
*
Phone #
*
Family Physician
Specialist
Preferred method of payment
*
Cash
Interac
Visa
Mastercard
Finanical Information: Person responsible for account
*
Self
Spouse
Other
DENTAL HISTORY
Date of last dental exam
*
MM slash DD slash YYYY
Cleaning
MM slash DD slash YYYY
Xrays
MM slash DD slash YYYY
PLEASE CHECK YES OR NO
Is there a problem you would like treated immediately?
*
Yes
No
Have you ever had periodontal treatment (treatment of the gums)?
*
Yes
No
Have you ever had orthodontics (straighten your teeth)?
*
Yes
No
Have you ever had a bite plate or nightguard?
*
Yes
No
Have you ever had your bite adjusted or teeth ground?
*
Yes
No
Have you ever had oral surgery to your mouth or jaw?
*
Yes
No
Are you currently seeing a dental specialist?
Yes
No
Are there any growths or sores in your mouth?
*
Yes
No
Do your gums bleed when brushing or do you suffer pain and swelling?
*
Yes
No
Have you noticed any loose teeth, or have any of your teeth shifted?
*
Yes
No
Does food catch between your teeth?
Yes
No
Are any of your teeth sensitive to hot, cold or sweets?
*
Yes
No
Have you been advised to take antibiotics before a dental appointment?
*
Yes
No
Do you use dental floss, proxabrush or stimudents?
*
Yes
No
How often?
Do you feel you have bad breath?
*
Yes
No
How often do you brush your teeth ?
*
Have you ever experienced any popping/clicking/pain in your jaw around your ear?
*
Yes
No
Any difficulty opening or closing/pain when teeth are clenched?
*
Yes
No
Do you clench or grind your teeth?
*
Yes
No
Do you bite your cheeks or lips?
*
yes
No
Do you have any emotional concerns about having dental treatment?
*
Yes
No
Are you happy with the appearance of your teeth?
*
Yes
No
MEDICAL HISTORY
Are you being treated for any medical conditions at present or within the past 2 years?
*
Yes
No
Have you been hospitalized in the past 2 years?
*
Yes
No
When was your last visit to your family doctor?
*
Last physical?
*
Are you presently taking any prescription or non-prescription drugs?
*
Yes
No
If yes, please list
Have you ever had a reaction to any medications?
*
Yes
No
If yes, please list
Have you ever been advised against medications?
*
Yes
No
Do you have any of the following: Asthma, Hay Fever, Food Allergies, Metal Allergies, Latex Allergies, Hives or any other allergic conditions?
*
Yes
No
Do any of these allergic conditions result in headache, nausea, swelling or shortness of breath?
*
Yes
No
Are you taking any vitamins or herbal supplements?
*
Yes
No
Has a family member ever had diabetes?
*
Yes
No
Do you bleed excessively from a cut or injury, or bruise easily?
*
Yes
No
Do your ankles, feet or hands swell?
*
Yes
No
Has your weight, appetite or energy level changed dramatically recently?
*
Yes
No
Do you experience shortness of breath or chest pain when walking or climbing stairs?
*
Yes
No
Do you follow a special diet?
*
Yes
No
Have you tested HIV positive
*
Yes
No
Do you have frequent severe headaches, earaches, ear/throat infections?
*
Yes
No
Have you ever had any injury to your face or jaw?
*
Yes
No
Do you wear eyeglasses or contact lenses?
*
Yes
No
Do you have any hearing difficulties?
*
Yes
No
Do you smoke or use any other form of tobacco?
*
Yes
No
Are you wearing a transdermal nicotine patch?
*
Yes
No
Are you alcohol or drug dependent?
*
Yes
No
Check off any of the following you presently have or ever had:
AIDS
Anemia
Angina pectoris
Arthritis/Rheumatism
Artifical heart valve
Artificial joints (hip, knee)
Blood disorders
Bronchitis
Botox
Cancer
Chiropractic care
Circulation problem
Congenital heart lesions
Cortisone/Steroid
Diabetes
Emphysema
Epilepsy or seizures
Fainting or dizzy spells
Glandular disorders
Glaucoma
Head/Neck injuries
Heart disease or attack
Heart murmur
Heart pacemaker
Heart rhythm disorder
Heart surgery
Hepatitis A, B, C
Herpes
HIV Positive
High/Low blood pressure
Hodgkin's disease
Hyper/Hypo Glycemia
Hypertension
Jaundice
Kidney disease
Liver disease
Lung disease
Lupus
Malignant hyperthermia
Migraine headache
Mental or nervous disorder
Mitral valve prolapse
Organ Transplant
Osteoporosis
Psychiatric treatment
Radiation treatment/chemo
Rheumatic fever
Scarlet fever
Sickle cell disease
Sinus trouble
Stomach/intestinal problem
Stroke
Thyroid disease
Tuberculosis
Ulcers
Veneral disease
Other:
Are you taking a Bisphosphonates (i.e.: Fosamax)?
*
Yes
No
Has the child patient had any of the following recently:
Measles
Strep Throat
Mumps
Tonsillitis
Chicken Pox
Women only: Are you pregnant or suspect you may be pregnant?
Yes
No
Are you taking birth control?
Yes
No
Do you currently have, or have had in the past, any disease, condition or problem not listed?
*
Yes
No
Is there anything about your health that we need to be aware of?
*
Yes
No
Name
This field is for validation purposes and should be left unchanged.
Meet the Team
Dental Services
Prevention & Check Ups
Proactive Oral Hygiene Care
Dental Laser
Restoration
3D CEREC Technology
Endodontics Root Canal Treatment
White Filings
Extraction
Wisdom teeth
Inlays/Onlays
Same Day Dental Crown
Replacement
Dental implants
Dental bridges
Removable partial dentures
Complete dentures
Cosmetic Dentist
Smile Makeovers
Teeth Whitening
Porcelain Veneers
Cosmetic Bonding
Invisalign® Dentist
TMD
Sedation
Sleep Apnea
Metcalfe Dental Experience
613-237-7177
Book An Appointment
