Oral Surgery UMH Form Patient Type*AdultChildAdult Under GuardianshipName of Patient* First Last Email* Self Identification* Man Woman Other Non-Binary Date of Birth MM slash DD slash YYYY Address* Address Line 2 *Select ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal 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 No 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 No Please Describe:Are you taking any medications, non-prescription drugs or herbal supplements of any kind?* Yes No Please Describe:Do you have any allergies?* Yes No Please Describe:Have you ever had a peculiar or adverse reaction to any medicines or injections?* Yes No Please Describe:Do you have or have you ever had asthma?* Yes No Please Describe:Do you have or have you ever had any heart or blood pressure problems?* Yes No 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 No Please Describe:Do you have a prosthetic or artificial joint?* Yes No Please Describe:Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?* Yes No Please Describe:Have you ever had hepatitis, jaundice or liver disease?* Yes No Please Describe:Have you ever been hospitalized for any illnesses or operations?* Yes No 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 No Please Describe:Are there any conditions or diseases not listed above that you have or have had?* Yes No Please Describe:Do you smoke or use other nicotine products?* Yes No Please Describe:Do you or have you ever taken bisphosphonates or other anti-resorptive/bone strengthening medications? Yes No Please Describe:Are you nervous during dental treatment? Yes No Please Describe:Do you consume alcohol? Yes No 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 No 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 No Please Describe:Have you been diagnosed with sleep apnea? Yes No Please Describe:Have you ever had orthodontic treatment (Braces or Invisalign)? Yes No Please Describe:Have you experienced any jaw injuries? Yes No Please Describe:Have you ever had implant surgery in your jaw? Yes No Please Describe:Are you breastfeeding or pregnant? Yes No Please Describe:Do you have a disability or are a person with visual impairment Yes No 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 historyGeneral 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 aboveDate MM slash DD slash YYYY
