Annual Health History

Annual Health History Update:

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Address(Required)

This information is required by our clinical dental team to assist in proper diagnosis and treatment planning. All information is strictly confidential. Please check YES or NO to each question. If you are unsure of a question, please contact your dental provider.

Are you currently under the care of a physician?(Required)
Have you been hospitalized, had a serious injury or new allergies in the last year?(Required)
Has there been a change in your general health in the past year?(Required)
Have you had a new heart problem diagnosed or had any change in an existing heart problem?(Required)
Are you currently taking any prescription medications?(Required)
Has there been a change in your medications in the past 6 months?(Required)
Do you take over the counter medications on a regular basis?(Required)
Do you take any vitamins or herbal supplements on a regular basis?(Required)
Have you had a bone density test done in the past year?(Required)
Have you experienced a significant change in weight in the past year?(Required)
Are you breastfeeding or pregnant?(Required)
Are you having any dental problems or discomfort with your mouth?(Required)
Do your gums bleed when brushing/flossing?(Required)
Are you dissatisfied with the appearance of your teeth?(Required)

Financial Policies:

Our practice helps patients to collect their insurance benefits by completing the standard dental form. In all cases, the patient is fully responsible for the complete cost of treatment on the day of their appointment. We accept Visa, American Express, MasterCard, cash and debit card. A 50% deposit is required for all extensive treatment. The balance of the fee is to be paid following the completion of the extensive treatment plans we are happy to set up written payment plans. Emergency patients who are not regular patients of our office, and who have not established a credit rating with us, are expected to pay for services rendered. In the event that an emergency occurs after regular business hours, the fees incurred will include a full emergency exam fee, plus a fee for any treatment performed. We require 2 business days notice to change or cancel all appointments. Failure to do so may result in a $100 service fee. A service charge of $50 will be applied to any returned cheques. Any accounts sent to collections will be charged an administrative fee of $100.

Financial Policy Confirmation(Required)
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