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613•739•1827

WELCOME TO OUR DENTAL OFFICE

The information that is requested on this Questionnaire, Dental History and Medical History is essential to providing you with the highest standard of dental care. The protection and privacy of your personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly.

General Information

             
 
       
(Above information to be completed only if person responsible for account is other than self)
 
    
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Medical Information

       
 
The following information is required by the dentist to assist in proper diagnosis and treatment.

 

 

 

 
local anaesthesia (freezing)   aspirin   penicillin   iodine  
sulfonamide (sulfa)    barbiturates (sleeping pills)
heart murmur or other heart condition     hepatitis A/B
joint replacement (hip, knee)     venereal disease
rheumatism     hyper (hypo) glycemia
arthritis     high/low blood pressure
thyroid disease     any lung disease
scarlet fever     herpes
stomach/intestinal problems     drug addiction
jaundice     cancer
cancer     kidney disease
mental or nervous disorder     stroke
tuberculosis     sinus trouble
heart attack     rheumatic fever
epilepsy or seizures     AIDS     liver disease

   

   
      
IN ORDER TO AVOID COMPLICATIONS AS A RESULT OF A CHANGE IN YOUR MEDICAL CONDITION, IT IS IMPORTANT THAT YOU NOTIFY OUR OFFICE OF THESE CHANGES.


Dental History

     
       

   

   

 

 
 
 

       
   

GENERAL RELEASE


By clicking submit you agree to certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care.

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Conroy Dental Centre 2280 St. Laurent Blvd. Suite 100 Ottawa, ON K1G4K1

Phone: 613.739.1827 Fax: 613.739.4547