Crescent Oral Forms

Personal Details

All mandatory fields are marked with *

Title

First Name

Last Name

Initial

Date of Birth

Age

Occupation

OHIP Number

Gender

Other Gender

Weight

lbs

kg

Height

Home Street Address

Apt. #

City

Postal Code

Home Phone No

Only numbers allowed. No – or other symbols.

Cell Phone No

Only numbers allowed. No – or other symbols.

Business Phone No

Only numbers allowed. No – or other symbols.

Email

Additional Information

All mandatory fields are marked with *

Crescent Oral Surgery Location:

1940 Eglinton Ave.E. Suite 500, Toronto Ontario, M1L4R1

9350 Yonge Street Suite 206, Richmond Hill Ontario, L4C5G2

236 Wellington St.E. Suite 200, Aurora Ontario, L4H1J5

Who should we notify in case of emergency?

Name

Relationship

Day-time Phone #

Only numbers allowed. No – or other symbols.

Referral & Insurance Details

All mandatory fields are marked with *

Reason for Referral

X-Rays

Yes

No

Referring Dentist:

First Name

Last Name

Other Dentists you see:

First Name

Last Name

Family Doctor Information:

First Name

Last Name

Phone #

Only numbers allowed. No – or other symbols.

Street Address

Apt.#

Province

City

Postal Code

Other Doctor's Information:

First Name

Last Name

Phone#

Only numbers allowed. No – or other symbols.

Please note that procedures done in the office are not covered by OHIP

Do you have dental insurance?

Yes

No

Spousal Plan?

Yes

No

Other

Description

Carrier

Plan Sponsor

Plan Contract#

Plan Member Certificate

Health History

All mandatory fields are marked with *

The following information is required to enable us to provide you with the best possible care. All information is strictly private, and is protected by doctor-patient confidentiality. Please fill in the entire form.

Are you completing this form for another person?

Yes

No

Are you being treated for any medical condition at the present or have you been treated within the past year?

No

Yes (Explain reason)

When was your last physical exam?

Last Physical Exam

Do you wear contact lenses?

No

Yes

Have there been any changes in your general health in the past year?

No

Yes (Please Explain)

Have you ever been hospitalized for any illness or operations?

No

Yes (Please Explain)

Have you ever had an unfavourable reaction following dental treatment?

No

Yes (Please Explain)

Have you ever had excessive bleeding requiring special treatment?

No

Yes (Please Explain)

Check any of the following which you presently have or have had:

Do you have or have you had any other diseases or medical problems not listed on this form?

No

Yes(Please describe)

Are you currently taking any prescription medications , non-prescription medications or herbal supplements? If yes, please list medications (include prescription medications, non-prescription medication and herbal supplements)

No

Yes

Have you recently used a recreational/street drug ? (if you do not wish to write this down please inform your surgeon verbally). If yes, how often and when was the last use?

No

Yes

Do you have any allergies to medications, latex/rubber, food or other substances? If yes, please list.

No

Yes

How much do you smoke per day?

How much alcohol do you drink in a week?

Review & Submit

All mandatory fields are marked with *

PERSONAL DETAILS

Title

First Name

Last Name

Initial

Birthdate

Age

Occupation

OHIP Number

Gender

Weight lbs

Height

Home Address

Apartment #

City

Postal Code

Home Phone #

Cell Phone #

Business Phone #

Email Address

ADDITIONAL INFORMATION

Crescent Oral Surgery Location 1940 Eglinton Ave.E. Suite 500, Toronto Ontario, M1L4R1

Who should we notify in case of emergency?

Name

Relationship

Day-time Phone #

Where Did You Hear About Us? Dentist

REFERRAL & INSURANCE DETAILS

Reason for Referral

X-Rays No

Referring Dentist

First Name

Last Name

Other Dentist you see

First Name

Last Name

Family Doctor Information

First Name

Last Name

Phone#

Street Address

Apt.

Province

City

Postal Code

Other Doctor's Information

First Name

Last Name

Phone #

Do you have dental insurance? Yes

Spousal Plan? Yes

Carrier

Plan Sponsor

Plan Contract #

Plan Member Certificate

HEALTH HISTORY

If you are completing this form for another person, what's your name and relationship to the patient?

First Name

Last Name

Relationship

Are you being treated for any medical condition at the present or have been treated within the past year? No

When was your last physical exam?

Do your contact lenses? No

Have there been any changes in your general health in the past year? No

Have you ever been hospitalized for any illness or operations? No

Have you ever had an unfavourable reaction following dental treatment? No

Have you ever had excessive bleeding requiring special treatment? No

Are you pregnant? No

Are you breastfeeding? No

Check any of the following which you presently have or have had:

Do you have or have you had any other diseases or medical problems not listed on this form? No

Are you currently taking any prescription medications, non-prescription medications or herbal supplements? If yes, please medications, non-prescriptions medication and herbal supplements) No

Have you recently used a recreational/street drug? (if you do not wish to write this down please inform your surgeon verbally). If yes, how often and when was the last use? No

Do you have any allergies to medications, latex/rubber, food or other substances? If yes, please list. No

How much do you smoke per day?

How much alcohol do you drink in a week?

I hereby state that this medical history is, to the best of my knowledge, accurate and complete. If I ever have any changes in my health, or if my medicines change, I will inform the doctor without fail, if deemed advisable.

I grant permission for my physician or dentist to be contacted for details and advice and that my patient information can be disclosed to them.

I further authorize the taking of radiography, photographs, digital images or other diagnostic aids that are appropriate for a thorough evaluation, treatment planning and educational purposes.

I understand these may be shared electronically.

I further authorize the storage of my records at a secure off-site location.

I have read and agreed*

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Med History Form

person_outlinePersonal Details

add_to_queueAdditional Information

Crescent Oral Surgery Location:

Who should we notify in case of emergency?

Where did you hear about us?

groupReferral & Insurance Details

Referring Dentist:

Other Dentists you see:

Family Doctor Information:

Other Doctor's Information:

Do you have dental insurance?

Spousal Plan?

favorite_borderHealth History

Are you completing this form for another person?

Are you being treated for any medical condition at the present or have you been treated within the past year?

When was your last physical exam?

Do you wear contact lenses?

Have there been any changes in your general health in the past year?

Have you ever been hospitalized for any illness or operations?

Have you ever had an unfavourable reaction following dental treatment?

Have you ever had excessive bleeding requiring special treatment?

Check any of the following which you presently have or have had:

Do you have or have you had any other diseases or medical problems not listed on this form?

Are you currently taking any prescription medications , non-prescription medications or herbal supplements? If yes, please list medications (include prescription medications, non-prescription medication and herbal supplements)

Have you recently used a recreational/street drug ? (if you do not wish to write this down please inform your surgeon verbally). If yes, how often and when was the last use?

Do you have any allergies to medications, latex/rubber, food or other substances? If yes, please list.

How much do you smoke per day?

How much alcohol do you drink in a week?

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Personal Details

Additional Information

Referral & Insurance Details

Health History

Review & Submit