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    • All Services
    • Children’s Dental Services 
    • Crowns & Bridges
    • Dental Implants
    • Emergency Dentistry
    • Invisalign
    • Porcelain Veneers
    • Same Day Crowns
    • Sedation Dentistry
    • Sleep Apnea Treatment
    • Teeth Whitening
    • Tooth Extractions
  • Patient Resources
    • New Patients
    • CDCP
    • Forms
      • Intake Form
      • Informed Consent For Root Canal Treatment
      • Extraction/Socket Protection/Bone Grafting Consent
      • Implant Consent
      • Consent for Surgical Gum Treatment
    • Free Guides
  • Blog
  • Reviews
  • Contact
  • About Us
  • Services
    • All Services
    • Children’s Dental Services 
    • Crowns & Bridges
    • Dental Implants
    • Emergency Dentistry
    • Invisalign
    • Porcelain Veneers
    • Same Day Crowns
    • Sedation Dentistry
    • Sleep Apnea Treatment
    • Teeth Whitening
    • Tooth Extractions
  • Patient Resources
    • New Patients
    • CDCP
    • Forms
      • Intake Form
      • Informed Consent For Root Canal Treatment
      • Extraction/Socket Protection/Bone Grafting Consent
      • Implant Consent
      • Consent for Surgical Gum Treatment
    • Free Guides
  • Blog
  • Reviews
  • Contact

New Patients: (613) 519-3999
Existing Patients: (613) 599-5076

Patient Information

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Other parental consent required(Required)

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In case of emergency, please notify:

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Please complete the following if you have dental insurance

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I authorize release to my dental benefits plan administrator information contained in claims and/or predeterminations(Required)

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

Are you being treated for any medical condition at the present or any time within the past year?(Required)
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Has there been any change in your general health in the past year?(Required)
Are you taking any prescription, non-prescription medications, or herbal supplements?(Required)
Do you have any allergies?(Required)
Have you ever had a peculiar or adverse reaction to any medicines or injections?(Required)
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Do you have or have you ever had asthma?(Required)
Do you have or have you ever had any heart or blood pressure problems?(Required)
Do you have or have you ever had an artificial heart valve, infection of the heart (i.e. #infective endocarditis), a heart condition from birth (i.e. congenital heart disease), or a heart transplant?(Required)
Do you have a prosthetic or artificial joint?(Required)
Do you have any conditions which may affect your immune system (i.e. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?(Required)
Have you ever had hepatitis, jaundice, or liver disease?(Required)
Do you have a bleeding problem or bleeding disorder?(Required)
Have you ever been hospitalized for any illnesses or operations?(Required)
Do you have, or have ever had any of the following? Please check(Required)
Are there any conditions/diseases not listed that you have or have had?(Required)
Are there any diseases/medical problems that run in your family (e.g. diabetes, cancer, heart disease, etc.)?(Required)
Do you smoke or chew tobacco products?(Required)
Are you nervous during dental treatment?(Required)
For women only: Are you pregnant or breastfeeding?
MM slash DD slash YYYY

Dental History

MM slash DD slash YYYY
How often do you see the dentist?(Required)
Have you ever whitened (bleached) your teeth?
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Contact Info

Address

9-300 Earl Grey Dr.
Kanata, ON K2T 1B9

Phone

New Patients: (613) 519-3999
Existing Patients: (613) 599-5076

Email

[email protected]

Hours
Monday8am – 7:30pm
Tuesday7:30am – 7:30pm
Wednesday7:30am – 7:30pm
Thursday7:30am – 7:30pm
Friday8am – 2:30pm
Saturday9am – 3pm
 (By Appointment Only)

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