West Ridge Family Dentistry | Medical History Update



	ATTENTION: The following information is required to enable us to provide you with the best possible dental care. All information collected is strictly confidential and is protected by doctor-patient confidentiality in accordance with the Personal Information Protection Act 2004. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form. All fields marked with an * are required. Personal Information First Name * Last Name * Home Details Street Address City Postal Code Insurance Information Insurance Company Policy# Certificate Medical Information Has there been any change in your health, such as a serious illness, hospitalization, or new allergies? Have you had a heart murmur diagnosed or had any changes in an existing cardiac problem or murmur? When was your last medical check up? Were any problems identified? Are you on any medications? (Please include dosage) Please provide the name of your pharmacy Are there any concerns or inquiries that you would like discussed with the Dentist/Hygienist? For women only: Are you breast feeding or pregnant Form Completed By Clear Form If a response is not received within your desired timeframe, please call us at (705) 329-1600.





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