Do you have any insurance benefits we can help you maximize?
Family Members at our practice:
Children: -
Best way to contact you:
My Favourite:
Please check any of the following problems that may apply to you.
Please share the following dates:
  -  If you could whiten your teeth for a cost anyone could afford, would you do it?
  -  Have you ever smoked?
Do you currently smoke?
  -  Are you nervous during dental treatment?
  -  I would be interested in different sedation options to make my visits more relaxing?
  -  Do you wish to speak privately to the doctor about any problem or medical condition?
If I could improve my oral health, I would...
One a scale of 1 (low) to 10 (high)...
How important is your dental health to you?
Where would you rate your current dental health?
How would you rate the look & feel of your smile?
Please check any of the following that apply to you:
Do you have any of the following allergies?
- Have you ever had a joint replacement? If yes, when?
- Has your physician ever told you to take antibiotics prior to dental procedures?
If so, why?
- Have you ever experienced complications following a medical or dental procedure?
If yes, please describe?
- Is there anything else you think we should know regarding your medical history?
If yes, please describe?
- Are you currently under a physician's care?
If yes, what for?
- Are you taking any medications/supplements?
If yes, please specify
How healthy would you like your teeth to be?
What quality of dentistry do you want us to recommend?
Privacy Information
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed with me. I understand that I am financially responsible to the dentist for the dental services provided.

Consent for Collection, Use and Disclosure of Personal Information
I agree that Village Dental Centre has obtained informed consent from me with respect to the collection, use and disclosure of my personal health information.
I have been provided with a copy of the consent form and agree that personal information may be collected, used and disclosed as set out in the Privacy Policy at this dental office and is in accordance with the Personal Health Information Protection Act, 2004.
I the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Village Dental Centre all insurance benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.