Patient Registration, Health History & Office Policies

Address:280 Guelph Street, Georgetown, ON, L7G 4B1
Phone Number: 905-877-2273

Welcome to Marketplace Dental Centre

In order to provide you with optimum dental care we require a thorough medical and dental history, which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.

Form Introductory Text

Personal Information

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Medical History (Confidential)

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Indicate which of the following conditions apply to you presently or in the past.

Are you in good health?*

Have you ever had a serious illness, operation, or hospitalization?*

Are you now taking any medicine, drugs, or pills?*

Do you have any blood disorders or do you bleed excessively?*

Do you have a tendency to faint?*

Are you on a special diet?*

Do you have a prosthetic implant? (i.e. hip?)*

Do you suffer from Diabetes?*

Do you take blood thinners?*

Do you smoke?*

Are you now under the care of a physician for any ongoing treatment or therapy?*

Do you have any allergies?*

Have you ever had injury, surgery, or x-ray therapy to face or jaws?*

Do you have frequent severe headaches?*

Rheumatic or Scarlet Fever?*

Do you have high blood pressure?*

Do you bleed excessively?*

WOMEN ONLY - Are you pregnant?*

Dental History

Do you see a dentist on a routine basis?*

Have you ever had Orthodontic treatment (Braces)?*

Have you ever had Periodontal treatment (Gum Surgery)?*

Have you noticed any loosening of your teeth?*

Do you suffer from pain and/or swelling of your gums?*

Have you ever experienced clicking of the jaw?*

Have you ever experienced difficulty in opening or closing?*

Do you: Clench or grind your teeth while awake or asleep?*

Do you: Hold foreign objects with your teeth (such as pencils, pipe, pins, nails, fingernails)?*

Do you feel nervous about having dental treatment?*

Is it important to keep your teeth?*

Are you having pain at this time?*

Have you ever had Oral Surgery?*

Have you ever worn a bite guard or other appliance?*

Does food tend to become caught between your teeth?*

Do your gums often bleed when you brush your teeth?*

Have you ever experienced pain (joint, ear, side of face)?*

Have you ever experienced difficulty in chewing?*

Do you: Bite your lips or cheeks regularly?*

Do you: Mouth breathe while awake or asleep?*

Have you ever had an upsetting experience in a dental office?*

Are you dissatisfied with the appearance of your teeth?*

General Consent Statement: I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge, and have not knowingly omitted any information. I authorize the dentist to perform necessary diagnostic procedures and treatments to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive.*

Office Policies

In an effort to ensure your appointments are as pleasant and predictable as possible, we would like to give you an overview of our office policies. Please feel free to call us with any questions you may have.

About Insurance Billing
Due to the Canadian Personal Privacy Act, we are unable to access any sufficient information from your insurance company regarding your dental plan. It is your responsibility to know the details involved in your plan such as annual maximums, frequencies, and any other limitations.

In the event that your insurance provider does not pay the expected amount for whatever reason, you are responsible to pay your account in full. All accounts will be subject to a late fee of 2% per month, 30 days after a statement of account has been issued.

Your Appointment Reminders
Please understand that it is your responsibility to keep track of your appointments. We do everything we can to remind you of them in adequate time for you to make arrangements or changes for that appointment. As a courtesy, we will call you one week prior to a booked appointment and try to make confirmation calls one day prior to your appointment. Unfortunately, that is all we are able to do in order to remind you of the upcoming appointments, after that it is up to you to remember.

Our Cancellation Policy
Should you require to cancel or change an appointment please provide us with 24 hours notice to avoid a $100 fee that our dental office may charge to you.

Our desire is for you to have a pleasant experience in our office. We strive to serve you to the best of our ability in helping you attain maximum dental health.

I confirm that*

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