R U SMILING
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What has changed since we last saw you?

Your dentist has to know about anything new in your health before treating you. Six questions, and you can tell us on the phone instead on 647-343-1171 if you would rather.

Your medical history update

These are the questions the College asks us to put to every returning patient. Answer all six, even where the answer is no — a blank tells your dentist nothing.

So we can find your chartthe same details the office already holds

Date of birth

so two patients with one name are not confused

in case the desk needs to check something

Has there been any change in your health, such as any serious illnesses, hospitalizations or new allergies?
Are you taking any new medications or have there been any change in your medications?
Have you had a new heart problem diagnosed or had any change in an existing heart problem?
When was your last medical checkup?

a date, or roughly when — “about a year ago” is a real answer

Were any problems identified?
Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?

Patient Certification

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

The name you type is your signature. We record it with the date you send this.

Check and sendnothing has been sent yet

Your medical history update

Full name
Not answered
Date of birth
Not answered
Mobile phone
Not answered
Has there been any change in your health, such as any serious illnesses, hospitalizations or new allergies?
Not answered
Are you taking any new medications or have there been any change in your medications?
Not answered
Have you had a new heart problem diagnosed or had any change in an existing heart problem?
Not answered
When was your last medical checkup?
Not answered
Were any problems identified?
Not answered
Are you breastfeeding or pregnant?
Not answered
Patient Certification
Not answered
Patient/parent/guardian/substitute decision-maker name
Not answered
Relationship to patient, if applicable
Not answered

Nothing leaves this page until you press send.