New Patient Forms

Patient Medical History PDF

You can send the new patient form to: info@uplandsdentalclinic.com

Or fill out the form here:

Medical & Dental History

Uplands Dental Clinic — Dr. Leigh & Associates

Patient Information

Title

Patient Name *

Date of Birth *

Age *

Gender *
MaleFemaleOther

Address (Street Name, Unit #) *

City *

Province *

Postal Code *

Primary Phone *

Secondary Phone

Preferred Contact Method *
PhoneEmail

Patient Email Address *

Family Physician Information

Family Physician Name

Physician Phone

Physician Email

Emergency Contact Information

Emergency Contact *

Primary Phone *

Relationship *

Medical Information

Do you have or have you ever had any of the following? (Check all that apply)

Please specify any additional details to supplement the previous section (e.g., Cancer, Joint Replacement dates, Transplants, Tumours, Other details)

Please list any medications/supplements being taken (attach a list if multiple)

Optional: Upload a list of medications (PDF, JPG, PNG):

Please list any known allergies

Please list any hospitalizations in the past 2 years

Please list any surgeries

Please list any recreational substances you take and frequency

Do you suffer from, or have a family history of malignant hyperthermia? *
YesNo

Are you taking blood thinners? *
YesNo

Do you have problems with your bleeding time? *
YesNo

WOMEN ONLY

Are you pregnant? *
YesNo

If yes, how many months?

Are you nursing? *
YesNo

Dental Information

When was your last dental visit?

What was the reason for your visit?

Are you having any problems that require immediate attention?

Are you nervous during dental treatment? *
YesNo

Are you interested in any of the following? (Check all that apply)

Policy & General Release

Cancellations and Missed Appointments

Your appointment time has been exclusively for you to see the dentist or hygienist. We ask that you give us at least 48 hours advance notice when cancelling your scheduled appointment so that we may offer the time to another patient.

General Release

I, the undersigned, certify that I have provided an accurate and complete personal, medical and dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical and dental history. Should there be any change in either my health status or any other information I have provided I will advise this dental office. I understand that information provided from or to my medical doctor or healthcare provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used, and disclosed within the guidelines of the policy. I understand that my dental insurance may not cover entirely the total fee of services provided. 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.

I have read, understood, and agree to the General Release and Cancellation Policy above. *

Signature (Patient/Guardian) *

Date *

Dentist Signature (Office Use Only)

Date (Office Use Only)

Medical & Dental History

WOMEN ONLY

Cancellations and Missed Appointments

General Release

Contact Us

Office Hours