Oral Surgery UMH Form

Patient Type*

Name of Patient*

First Last

Email*

Self Identification*

Man

Woman

Other

Non-Binary

Date of Birth

MM slash DD slash YYYY

Address*

Address Line 2

Postal code

Primary Phone Number*

Home Phone Number

Work Phone Number

Best number to reach you at?*

Primary

Home

Work

Height

Weight

Health Card Number

Health Card Expiry

Mode of transportation home ( after surgery ):

Post surgery pick up information: ( Name of contact ):

Name of Primary Insurance*

Name of Secondary Insurance (If applicable)*

Preferred method of contact?*

SMS

Phone

Mobile

Preferred method of payment?*

VISA

Mastercard

Interac

Phone number of Parent/ Guardian

Person responsible for the account

Family Doctor ( Please write the Doctors name and phone number )

General Dentist ( Please write the Dentists name and phone number )

Pharmacy ( Please write the pharmacy name and phone number )

In case of emergency, we should notify:

First Last

Emergency contact relationship:

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

Yes

Please Describe:

When was your last medical checkup?

MM slash DD slash YYYY

Has there been any change in your general health in the past year?*

Yes

Please Describe:

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*

Yes

Please Describe:

Do you have any allergies?*

Yes

Please Describe:

Have you ever had a peculiar or adverse reaction to any medicines or injections?*

Yes

Please Describe:

Do you have or have you ever had asthma?*

Yes

Please Describe:

Do you have or have you ever had any heart or blood pressure problems?*

Yes

Please Describe:

Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?*

Yes

Please Describe:

Do you have a prosthetic or artificial joint?*

Yes

Please Describe:

Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*

Yes

Please Describe:

Have you ever had hepatitis, jaundice or liver disease?*

Yes

Please Describe:

Have you ever been hospitalized for any illnesses or operations?*

Yes

Please Describe:

Do you have or have you ever had any of the following? Please check all that apply.*

chest pain, angina

rheumatic fever

pacemaker

steroid therapy

seizures (epilepsy)

heart attack

mitral valve prolapse

lung disease

diabetes

kidney disease

stroke, TIA

tuberculosis

stomach ulcers

thyroid disease

shortness of breath

heart murmur

cancer

arthritis

drug/alcohol/cannabis use or dependency

osteoporosis medications (e.g. Fosamax, Actonel)

loss of hearing

difficulty hearing

None of the above

Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer, heart disease)*

Yes

Please Describe:

Are there any conditions or diseases not listed above that you have or have had?*

Yes

Please Describe:

Do you smoke or use other nicotine products?*

Yes

Please Describe:

Do you or have you ever taken bisphosphonates or other anti-resorptive/bone strengthening medications?

Yes

Please Describe:

Are you nervous during dental treatment?

Yes

Please Describe:

Do you consume alcohol?

Yes

Please Describe:

If you consume alcohol, how many times a week?

Everyday

Every other day

Every week

A few times a month

None of the above

Do you use recreational drugs?

Yes

Please Describe:

If you use recreational drugs, how many times a week?

Everyday

Every other day

Every week

A few times a month

None of the above

WOMEN ONLY

Pregnant

Nursing

Every week

Taking birth control

Do you clench or grind your teeth?

Yes

Please Describe:

Have you been diagnosed with sleep apnea?

Yes

Please Describe:

Have you ever had orthodontic treatment (Braces or Invisalign)?

Yes

Please Describe:

Have you experienced any jaw injuries?

Yes

Please Describe:

Have you ever had implant surgery in your jaw?

Yes

Please Describe:

Are you breastfeeding or pregnant?

Yes

Please Describe:

Do you have a disability or are a person with visual impairment

Yes

Please Describe:

Have you ever had any complications or issues with previous dental treatment?

Please list anything else not mentioned above regarding your past dental history

General Release

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history to the best of my ability and have not knowingly omitted any information. I have had an opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that the information provided from or to my medical doctor or another health care provider may be necessary, and I consent to the release of this information. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. The patient agrees that the relationship between himself or herself and the dentist shall be governed and construed in accordance with the laws of the province of Ontario.

Signature*

Use your mouse or finger to draw your signature above

Date

MM slash DD slash YYYY