R U SMILING
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Your first visit, filled in before you arrive.

Five short steps: who you are, your medical history, the conditions the dentist asks about, your dental history and cover, and the practice’s policies. Nothing is sent until you have read it back. Rather do it at the desk? Call 647-343-1171 and we will hand you the paper form when you arrive.

Already a patient?Update your medical history instead

Patient informationas it appears on your health card

What you would rather be called at the desk.

Date of birth (required)

The patient’s own birthday — not yours, if you are filling this in for somebody else.

Gender

Address

The desk calls this number to confirm appointments and to reach you about a change.

A second number, if there is one the desk may use.

Who should we call in an emergency?someone other than you

Health-care providersso we can write to them if your care needs it

Do you have a family doctor or primary health-care provider?
Do you see any medical specialists?
Medical specialists you see

One row for each. Add the ones you can remember; the desk asks again in the chair.

No specialists listed yet.

General medical history

Please answer every question. Your information is confidential and helps us provide safe dental care.

Are you currently being treated for a medical condition, or have you been treated within the past year?
When was your last medical checkup?

Roughly is fine — “about two years ago”.

Has your general health changed during the past year?
Are you taking any prescription medication, non-prescription medication, vitamins or herbal supplements?
Please list what you take.

One line each. Leave a cell blank if you are not sure of it.

Nothing listed yet.

Do you have any allergies?
Please list your allergies.

One line each, with the category that fits it best.

Nothing listed yet.

Have you ever had an unusual or adverse reaction to a medication, injection or local anesthetic?
Do you have, or have you ever had, asthma?
Do you have, or have you ever had, heart or blood-pressure problems?
Have you had a replacement or repaired heart valve, infective endocarditis, congenital heart disease or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have a condition or treatment that affects your immune system, including HIV, leukemia, chemotherapy, radiotherapy or transplant medication?
Have you ever had hepatitis, jaundice or liver disease?
Do you have a bleeding disorder, unusual bruising or prolonged bleeding?
Are you taking aspirin, anticoagulants or other medications that affect bleeding?
Have you ever been hospitalized for an illness or operation?

For womenChoose “Not applicable” if a question does not apply to you.

Are you using birth control?
Have you reached menopause?

Conditions and additional informationabout 3 minutes

The conditions come first, grouped by part of the body. Everything else the dentist needs to know about is below them.

Medical conditions

Please answer every list, even the ones that do not apply to you — None is a real answer and tells the dentist as much as a tick does.

Cardiovascular

Respiratory

Endocrine, metabolic & renal

Gastrointestinal

Neurological

Hematologic & immune

Musculoskeletal

Other

Do any significant medical conditions run in your family, such as diabetes, cancer or heart disease?
Do you smoke, vape or chew tobacco or nicotine products?
Are you nervous or anxious during dental treatment?

For womenChoose “Not applicable” if a question does not apply to you.

Are you currently pregnant?
Are you currently breastfeeding?
Do you identify as a person with a disability or as Deaf, or require an accommodation?

Anything else

Write it here, or tick the box below.

Nothing to add

Dental history and insurancea rough answer is fine

Dental history

Have you been seeing a dentist regularly?

Roughly is fine — “about two years ago”. “Never” and “I’m not sure” are answers too.

Roughly is fine — “about two years ago”. “Never” and “I’m not sure” are answers too.

Have you previously seen a dental specialist?
Have you had a bad experience or complication during dental treatment?
Have you been instructed to take antibiotics before dental appointments?
How often do you brush?
How often do you floss or use another interdental cleaner?
Do your gums bleed when brushing or flossing?
Do you have jaw pain, clicking or restricted movement?
Have you injured your teeth or jaws, including in a motor-vehicle accident?
Do you have concerns about bad breath or the appearance of your teeth?

Dental insurance

Do you have dental insurance?the desk checks your coverage before the visit either way
Main policy holder’s date of birth

From your benefits card. Leave the ones without “(required)” blank if you do not have them to hand.

Do you have secondary insurance?a spouse’s or a parent’s plan, if you are on one
Main policy holder’s date of birth

From your benefits card. Leave the ones without “(required)” blank if you do not have them to hand.

Appointments

When you make an appointment with our office, we consider this a mutual commitment and reserve appropriate facilities and staff exclusively for you. Our Office Policy states that patients must give us 1 business day notice if they cannot keep an appointment time. Appointment changes with less than 1 business day notice are subject to a service fee based on the amount of time that was allocated and reserved for you.

Payment

Payment in full is due the day of treatment, or upon the start of major treatment. Dental Insurance Plans often pay less than the actual fee for service; should a patient have dental insurance with assignment to R U Smiling Dental, the estimated patient portion will be the amount due the day of treatment. For your convenience, we accept Cash, Debit, Visa, Mastercard. The patient is responsible for any amount not covered by their plan.

Examination and Information Authorization

I consent to an initial dental examination by the dentists and authorized oral-health providers at R U Smiling Dental.

I authorize the practice to use and disclose relevant dental and medical information to insurers and other health-care providers for payment, referral and continuity-of-care purposes, as permitted by law.

This authorization does not replace the informed-consent discussion required for any proposed treatment or procedure.

I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatments performed. I authorize and request my insurance company to pay my benefits directly to providers of R U Smiling Dental.

I certify that the medical and dental information I provided is accurate and complete to the best of my knowledge. I understand that this information is important for safe care, and I agree to notify R U Smiling Dental about future changes in my health, allergies or medications.

Please read the above, then enter your Full Name and sign below. Your signature is recorded on the date of this form submission.

Leave this blank if you are the patient.

Type your signature

Your typed name is your signature, and is recorded with the date the form is sent.

Check and sendnothing has been sent yet

Patient information

Legal first name (required)
Not answered
Preferred name
Not answered
Date of birth (required)
Not answered
Gender
Not answered
Address
Ontario
Mobile phone (required)
Not answered
Home or work phone
Not answered
Email (required)
Not answered
Full name (required)
Not answered
Relationship to you (required)
Not answered
Daytime phone (required)
Not answered
Do you have a family doctor or primary health-care provider?
Not answered
Do you see any medical specialists?
Not answered

General medical history

Are you currently being treated for a medical condition, or have you been treated within the past year?
Not answered
Date or approximate date
Not answered
Has your general health changed during the past year?
Not answered
Are you taking any prescription medication, non-prescription medication, vitamins or herbal supplements?
Not answered
Do you have any allergies?
Not answered
Have you ever had an unusual or adverse reaction to a medication, injection or local anesthetic?
Not answered
Do you have, or have you ever had, asthma?
Not answered
Do you have, or have you ever had, heart or blood-pressure problems?
Not answered
Have you had a replacement or repaired heart valve, infective endocarditis, congenital heart disease or a heart transplant?
Not answered
Do you have a prosthetic or artificial joint?
Not answered
Do you have a condition or treatment that affects your immune system, including HIV, leukemia, chemotherapy, radiotherapy or transplant medication?
Not answered
Have you ever had hepatitis, jaundice or liver disease?
Not answered
Do you have a bleeding disorder, unusual bruising or prolonged bleeding?
Not answered
Are you taking aspirin, anticoagulants or other medications that affect bleeding?
Not answered
Have you ever been hospitalized for an illness or operation?
Not answered
Are you using birth control?
Not answered
Have you reached menopause?
Not answered

Conditions and additional information

Cardiovascular
Not answered
Respiratory
Not answered
Endocrine, metabolic & renal
Not answered
Gastrointestinal
Not answered
Neurological
Not answered
Hematologic & immune
Not answered
Musculoskeletal
Not answered
Other
Not answered
Do any significant medical conditions run in your family, such as diabetes, cancer or heart disease?
Not answered
Do you smoke, vape or chew tobacco or nicotine products?
Not answered
Are you nervous or anxious during dental treatment?
Not answered
Are you currently pregnant?
Not answered
Are you currently breastfeeding?
Not answered
Do you identify as a person with a disability or as Deaf, or require an accommodation?
Not answered
Is there anything else the dentist should know about your health?
Not answered

Dental history and insurance

What is the reason for today’s visit? Are you experiencing a dental problem?
Not answered
Have you been seeing a dentist regularly?
Not answered
When was your last dental visit, and what was done? (required)
Not answered
When were your last dental X-rays taken? (required)
Not answered
Have you previously seen a dental specialist?
Not answered
Have you had a bad experience or complication during dental treatment?
Not answered
Have you been instructed to take antibiotics before dental appointments?
Not answered
How often do you brush?
Not answered
How often do you floss or use another interdental cleaner?
Not answered
Do your gums bleed when brushing or flossing?
Not answered
Do you have jaw pain, clicking or restricted movement?
Not answered
Have you injured your teeth or jaws, including in a motor-vehicle accident?
Not answered
Do you have concerns about bad breath or the appearance of your teeth?
Not answered
Do you have dental insurance?
Not answered
Do you have secondary insurance?
Not answered
Office Policies and Consent
Not answered
Patient Certification
Not answered
Patient/parent/guardian/substitute decision-maker name
Not answered
Relationship to patient, if applicable
Not answered

Nothing is sent until you press this. You can go back and change any answer.